LDL Cholesterol in CKD :

to treat or not to treat?

Prof. Dr. dr. Suhardjono, SpPD-KGH

 Reduced GFR* increases
cardiovascular risk
6.0

5.0
Relative risk* in patients with

impaired GFR (95% CI)

4.0

3.0

2.0

Increased risk
1.0
Reduced risk

0.0
Major Myocardial Stroke Cardiovascular Total
cardiovascular infarction mortality mortality
event
*Relative risk of GFR 60 mL/min/1.73m2
compared with GFR >60 mL/min/1.73m2
Ruilope et al. J Am Soc Nephrol 2001;12:218225
 Cardiovascular Disease Risk Factors
in Chronic Kidney Disease

CKD is risk factor for CVD and is associated with an

increase in all cause mortality
Among those with ESRD, 50% of all deaths are due
to CVD, and the risk of CVD is 10 to 20 times higher
than in the general population
The etiology is unknown, but may in part be to
shared CVD risk factors, including diabetes,
hypertension, obesity, lipid abnormalities and
smoking
The burden of CVD risk factors among patients who
have not undergone dialysis and those who have is
extremely high
Parikh NI et all, Arch of Intern Med 2006;166:1884-1891
 Causes of CV Mortality in CKD

~25%: Directly attributable to MI

(potentially avoidable
with cholesterol reduction)

~75%: Other causes (cardiac

arrest, arrhythmia, heart
failure)
Not as dependent on
cholesterol reduction

Adapted from Baigent C, et al: Kidney Int Suppl 2003; (84):S207-10.

 Risk of CVD in CKD patients

Cardiovascular
Disease

Inflammatory mediators
Oxidative injury
GFR and Lipoprotein
Proteinuria Abnormalities
Insulin resistance
Other mediators

Kidney Injury

(Weiner, 2004)
 Results of All Risk Factors in Kidney
Disease

Anemia GFR
PTH ET
Uremia related
PO4 CRP

Hypertension Smoking High oxidant stress Modifiable

Dyslipidemia Homocysteine (+/-) Inflammation

Age Family History

Non modifiable
Gender Diabetes
 Consequences of Renal Dyslipidemia

Cardiovascular disease (CVD) is the main cause

of mortality during dialysis and after renal
transplantation

The accelerated development of atherosclerosis

and CVD in progressive renal disease is well
documented

The prevalence of CVD is also high in renal

patients in the early stages of CKD, long before
the time of initiating dialysis

Adapted from Attman PO, et al: Curr Opin Lipidol 2009; 20(4):293-9.
Landray et al. AJKD 2001; 38: 537-46
Landray et al. AJKD 2001; 38: 537-46
Landray et al. AJKD 2001; 38: 537-46
 Pada orang dewasa yang baru
diidentifikasi sebagai PGK (termasuk
yang menjalani dialisis atau
transplantasi) direkomendasikan untuk
pemeriksaan profil lipid.
Pemeriksaan ulang profil lipid tak
diperlukan bagi mayoritas pasien diatas.
 Statin atau kombinasi statin/ezetimibe;
dianjurkan pada usia >50 tahun,
eLFG<60 ml/min, G3a-G5 yang belum
dialisis.
Pada dewasa >50 tahun, G1- G2
Pada dewasa 18-49 tahun, apabila
terdapat PJK, DM, stroke iskemik,
estimasi 10 tahun kematian koroner
atau IM >10%
 Tidak mulai diberi statin atau kombinasi
statin-ezetimibe pada pasien dengan
dialisis
Apabila saat mulai dialisis sudah
mendapat obat, dapat dilanjutkan
Pada pasien dewasa transplantasi
dianjurkan diobati
 Fire-and-Forget

Existing evidence does not support a

specific on-treatment LDL cholesterol
target and thus adjusting the dose of
statin regimens based on LDL
cholesterol levels is not required.
This type of strategy has been termed
fire-and-forget.
 Advantages of a fire-and-
forget strategy
In persons with CKD include
simplicity,
lower resource consumption
(due to less unnecessary use of LDL
cholesterol testing and high-dose
statin regimens), and
reduced risk for side effects
 Statin: Risk and Benefit Ratio
Statins are important in rapid vascular
protection
Intensive treatment produces more benefits
Side effect
Statins are save and and well tolerated

Therapeutic effect

Myotoxicity
Liver toxicity
CV protection Renal Toxicity
Drug Interaction
 Conclusion

Cardiovascular events increased substantially with

progressively lower eGFR
CKD is an independent risk factor for myocardial
infarction, fatal coronary heart disease, stroke, and
death
Statin trials show that statins are helpful in all stages
CKD except stage 5 or dialysis. In addition, dose
adjusment is necessary in order to reduce side effects
Statin should be initiated early in the course of CKD
The treatment is simple, efficient, and doesnt need
frequent blood test Fire and Forget.
THANK YOU