Lipid-lowering agents for concurrent cardiovascular and chronic kidney disease

ABSTRACT

Introduction: Cardiovascular disease (CVD) frequently co-exists with chronic kidney disease (CKD). Patients with concomitant CVD and CKD are at very high risk of CVD events.

Areas covered: This narrative review discusses the use of hypolipidaemic drugs in patients with both CVD and CKD. Current guidelines are considered together with the evidence from randomised controlled clinical trials.

Expert opinion: Statins are the first-line lipid-lowering therapy in patients with CVD and CKD. Some statins require dose adjustments based on renal function, whereas atorvastatin does not. Ezetimibe can be prescribed in patients with CVD and CKD, usually combined with a statin. According to current guidelines, statin±ezetimibe therapy should not be initiated, but should be continued, in dialysis-treated CKD patients. Fenofibrate (dose adjusted or contra-indicated according to renal function) and omega 3 fatty acids lower triglyceride levels; whether they also exert cardiorenal benefits in patients with CVD and CKD remains to be established. The use of proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors, cholesterol-reducing nutraceuticals, bempedoic acid and apabetalone in such patients should be investigated. Patients with concomitant CVD and CKD should be treated, in terms of lipid-lowering therapy, early and intensively to minimize their very high risk and possibly, progression of CKD.

KEYWORDS:

• Cardiovascular disease
• chronic kidney disease
• ezetimibe
• fenofibrate
• omega 3 fatty acids
• proprotein convertase subtilisin-kexin type 9 inhibitors
• statins

Article Highlights

• Patients with concomitant cardiovascular disease (CVD) and chronic kidney disease (CKD) are at very high risk of CVD events.

• Statins should be prescribed in CVD patients (with or without CKD); ezetimibe, with or without a statin, should be administered when LDL-C goals cannot be achieved by the maximum tolerated statin dose or in cases of statin intolerance, respectively.

• Statin ± ezetimibe therapy should not be initiated in dialysis-treated CKD patients (without established CVD) but could be continued if already initiated.

• More data are needed for the use of PCSK9 inhibitors in CKD patients.

• Fenofibrate and omega 3 fatty acids may be useful in cases of hypertriglyceridaemia. Fenofibrate dose adjustments are required for different stages of CKD; it should not be administered in patients with GFR <15 ml/min/1.73m² or on dialysis.

• Lipid-lowering nutraceuticals, bempedoic acid and apabetalone may represent potential therapeutic options in patients with concomitant CVD and CKD. However, there is a need for further evidence.

This box summarizes key points contained in the article.

Declaration of interest

N Katsiki has given talks, attended conferences and participated in trials sponsored by Amgen, Angelini, Astra Zeneca, Boehringer Ingelheim, Elpen, Mylan, NovoNordisk, Sanofi and Servier. DP Mikhailidis has given talks and attended conferences sponsored by Amgen, AstraZeneca and Libytec. M Banach has served on the speakers’ bureau of Abbott/Mylan, Abbott Vascular, Actavis, Akcea, Amgen, Biofarm, KRKA, Merck Sharp and Dohme, Sanofi, Servier and Valeant, and has served as a consultant to Abbott Vascular, Akcea, Amgen, Daichii Sankyo, Esperion, Eli Lilly and Company, Merck Sharp and Dohme, Resverlogix and Sanofi. He has also received grants from Sanofi and Valeant. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose

Additional information

Funding

This manuscript has not been funded.