Statins for Non-Dialysis Chronic Kidney Disease

摘要

Dyslipidemia is common in patients with chronic kidney disease (CKD) and contributes to cardiovascular disease and worsening renal function. Statins are widely used in non-dialysis dependent CKD (pre-dialysis), even though evidence favoring their use is lacking. To evaluate the benefits and harms of statins in patients with CKD who were not receiving renal replacement therapy. The authors searched Medline, EMBASE, and CENTRAL (in The Cochrane Library), and hand-searched reference lists of textbooks, articles, and scientific proceedings. Randomized controlled trials (RCTs) and quasi-RCTs comparing statins with placebo, no treatment, or other statins in adult patients with pre-dialysis CKD. Two authors independently assessed study quality and extracted data. Results were expressed as mean difference (MD) for continuous outcomes (lipids, creatinine clearance, and proteinuria) and risk ratio (RR) for dichotomous outcomes (all-cause mortality, cardiovascular mortality, fatal and nonfatal cardiovascular events, elevated liver enzymes, rhabdomyolysis, and withdrawal rates) with 95% confidence intervals (CIs). Twenty-six studies (25,017 participants) comparing statins with placebo were identified. Total cholesterol levels decreased significantly with statins (18 studies, 1,677 patients: MD = -41.48 mg per dL; 95% CI, -49.97 to -33.99). Similarly, low-density lipoprotein cholesterol decreased significantly with statins (16 studies, 1,605 patients: MD = -42.38 mg per dL; 95% CI, -50.71 to -34.05). Statins decreased the risk of all-cause deaths (21 RCTs, 18,781 patients; RR = 0.81; 95% CI, 0.74 to 0.89) and cardiovascular deaths (20 studies, 18,746 patients; RR = 0.80; 95% CI, 0.70 to 0.90). Statins decreased 24-hour urinary protein excretion (six studies, 311 patients; MD = -0.73 g per 24 hours; 95% CI, -0.95 to -0.52), but there was no significant improvement in creatinine clearance, which is a surrogate marker of renal function (11 studies, 548 patients; MD = 1.48 mL per minute; 95% CI, -2.32 to 5.28). The incidence of rhabdomyolysis, elevated liver enzymes, and withdrawal rates due to adverse events (well known complications of statins use) were not significantly different between patients receiving statins and placebo. Statins significantly reduced the risk of all-cause and cardiovascular mortality in patients with CKD who were not receiving renal replacement therapy. They do not impact the decline in renal function as measured by creatinine clearance, but may reduce protein excretion in urine. Statins appear to be safe in this population. Guideline recommendations on hyperlipidemia management in patients with CKD could therefore be followed, targeting higher proportions of patients receiving a statin, with appropriate monitoring of adverse events.