We can't however ignore all the data with statins in general population with positive results. Stains are good to lower cholesterol and they impact survival in CVD. What Sharp shows from my point of view is that
1) in the CKD patients, the effect is not so good than in non-CKD patients. This has been shown in dialysis patients, too. maybe because the damage is already done and we are too late, maybe because other physiopathological insults are specifically involved in the CKD patients...
2) the role of statin on the progression of CKD is not proven (at all). Today, it seem not justified to give statin to stop or decrease progression of CKD
However, I will be be tempered : if a CKD patient is treated by statins for a long time before consulting the nephrologist, his CKD status is not an argument to STOP statin...In the same vein, if a CKD patient, has a very high cholesterol levels, is young and had other CV risk factors, it could be justified to treat him with statins, especially if the CKD stage is not too low (or higher than in the SHARP study)
A question, not resolved by SHARP and specific to nephrology:
Do you treat or not a young patient with no CV history, with no CV risk, with "normal" GFR but with very high cholesterol level, in the context of a nephrotic syndrome??
1) in the CKD patients, the effect is not so good than in non-CKD patients. This has been shown in dialysis patients, too. maybe because the damage is already done and we are too late, maybe because other physiopathological insults are specifically involved in the CKD patients...
2) the role of statin on the progression of CKD is not proven (at all). Today, it seem not justified to give statin to stop or decrease progression of CKD
However, I will be be tempered : if a CKD patient is treated by statins for a long time before consulting the nephrologist, his CKD status is not an argument to STOP statin...In the same vein, if a CKD patient, has a very high cholesterol levels, is young and had other CV risk factors, it could be justified to treat him with statins, especially if the CKD stage is not too low (or higher than in the SHARP study)
A question, not resolved by SHARP and specific to nephrology:
Do you treat or not a young patient with no CV history, with no CV risk, with "normal" GFR but with very high cholesterol level, in the context of a nephrotic syndrome??
For nephrotic syndrome my practice is:
NO TO STATINS, in the short term 8-12 weeks waiting for induced or spontaneous remission.
YES TO STATINS, in the long term after 12 weeks in those who show no sign of remission.
This is based on old data, that taught me that short term hyperlipidemia in a young, <50 years, individual is unlikely to do harm.
That long term, severe, hypercholesterolemia >6mmol/, may warrant treatment....NO EVIDENCE! This dates back to the debates as to whether those with Nephrotic syndrome are at higher risk of CVD; the data is probably not there and may be age and co-morbidity confounded.
NO TO STATINS, in the short term 8-12 weeks waiting for induced or spontaneous remission.
YES TO STATINS, in the long term after 12 weeks in those who show no sign of remission.
This is based on old data, that taught me that short term hyperlipidemia in a young, <50 years, individual is unlikely to do harm.
That long term, severe, hypercholesterolemia >6mmol/, may warrant treatment....NO EVIDENCE! This dates back to the debates as to whether those with Nephrotic syndrome are at higher risk of CVD; the data is probably not there and may be age and co-morbidity confounded.
Statin is an essential drug in the prescriptions for nephrotic syndrome patients from the start ..and i am one of those who prescribe them !!
even if the patient has MCD and will go to remission in most cases on high dose steroids within 4-8 weeks?????
Why give 2 potentially myotoxic drugs for no apparent benefit over such a short period of time...you may get the side effects for no known benefit Achraf?
Why give 2 potentially myotoxic drugs for no apparent benefit over such a short period of time...you may get the side effects for no known benefit Achraf?
No evidence for the use of statins in NS especially in children
1-www.ncbi.nlm.nih.gov/pubmed/21277007
A retrospective study , full of bias
2-reference.medscape.com/medline/abstract/15507504
CONCLUSIONS: Lowering cholesterol levels during childhood may reduce the risk for atherosclerotic changes and may thus be of benefit in certain patients with nephrotic syndrome. Statins have demonstrated short-term safety and efficacy in the pediatric nephrotic syndrome population. Implementing pharmacologic therapy with statins in children with nephrotic syndrome must be done with care until controlled studies are conducted in this population.
3- www.indianpediatrics.net/jan2009/35.pdf
Persistent dyslipidemia is an important risk factor for the occurrence of cardiovascular disease. In view of limited pediatric data, the above targets are in accordance with those proposed for adults. The target LDL level has been set as <130 mg/dL as
suggested by the Kidney Disease Outcome Quality Initiative (KDOQI) for adolescents with chronic kidney disease. There is evidence that control of dyslipidemia leads to control of proteinuria and regression of renal fat deposits (Level 4) Long-term studies are necessary to assess the beneficial effects of lipid lowering on renal histology and disease progression.
statins could be used for long term CVS protection in persistent NS
1-www.ncbi.nlm.nih.gov/pubmed/21277007
A retrospective study , full of bias
2-reference.medscape.com/medline/abstract/15507504
CONCLUSIONS: Lowering cholesterol levels during childhood may reduce the risk for atherosclerotic changes and may thus be of benefit in certain patients with nephrotic syndrome. Statins have demonstrated short-term safety and efficacy in the pediatric nephrotic syndrome population. Implementing pharmacologic therapy with statins in children with nephrotic syndrome must be done with care until controlled studies are conducted in this population.
3- www.indianpediatrics.net/jan2009/35.pdf
Persistent dyslipidemia is an important risk factor for the occurrence of cardiovascular disease. In view of limited pediatric data, the above targets are in accordance with those proposed for adults. The target LDL level has been set as <130 mg/dL as
suggested by the Kidney Disease Outcome Quality Initiative (KDOQI) for adolescents with chronic kidney disease. There is evidence that control of dyslipidemia leads to control of proteinuria and regression of renal fat deposits (Level 4) Long-term studies are necessary to assess the beneficial effects of lipid lowering on renal histology and disease progression.
statins could be used for long term CVS protection in persistent NS
The average LDL level in SHRP was 108mg/dL (near optimal for people at risk for heart disease – e.g CKD?).
SHARP evaluated the use of simvastatin+ezetimibe for preventing CVD events/mortality by lipid lowering in patients with CKD (not in patients with hyperlipidemia (LDL) or coronary heart disease/CHD).
There is enough evidence to treat hyperlipidemia or CHD by lipid lowering with statins.
There is no evidence to treat all CKD pateints with satins.
But to my best knowledge there is also no indication for NOT treating CKD patients with hyperlipidemia or CHD with statins (chronic RRT patients excluded?), unless CKD is vasculoprotective, which apparently it is not.
Of course anticipated transient hypelipidemia (e.g.MCD) should not necessarily promt statin treatment .
SHARP evaluated the use of simvastatin+ezetimibe for preventing CVD events/mortality by lipid lowering in patients with CKD (not in patients with hyperlipidemia (LDL) or coronary heart disease/CHD).
There is enough evidence to treat hyperlipidemia or CHD by lipid lowering with statins.
There is no evidence to treat all CKD pateints with satins.
But to my best knowledge there is also no indication for NOT treating CKD patients with hyperlipidemia or CHD with statins (chronic RRT patients excluded?), unless CKD is vasculoprotective, which apparently it is not.
Of course anticipated transient hypelipidemia (e.g.MCD) should not necessarily promt statin treatment .
My comments were on the SHARP study:
1. Its findings
2. Its misinterpretation
3. Its Spin
4. Its acceptance by the Nephrology community and the guidelines writers
As to draw attention to unaware nephrologists of what SHARP really showed and what it meant when it referred to improved MACE, etc...
It was NOT about the use by Nephrologists of Statins in clinical practice.
That lacks validated guidance, and we all do what we think is best for our patients, in the absence of supporting evidence. THis is what we do most of the time in our clinical practice; rely on our best judgement in the absence of a better alternative...
1. Its findings
2. Its misinterpretation
3. Its Spin
4. Its acceptance by the Nephrology community and the guidelines writers
As to draw attention to unaware nephrologists of what SHARP really showed and what it meant when it referred to improved MACE, etc...
It was NOT about the use by Nephrologists of Statins in clinical practice.
That lacks validated guidance, and we all do what we think is best for our patients, in the absence of supporting evidence. THis is what we do most of the time in our clinical practice; rely on our best judgement in the absence of a better alternative...
