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Pontremoli R, Bellizzi V, Bianchi S, Bigazzi R, Cernaro V, Del Vecchio L, De Nicola L, Leoncini G, Mallamaci F, Zoccali C, Buemi M. Management of dyslipidaemia in patients with chronic kidney disease: a position paper endorsed by the Italian Society of Nephrology. J Nephrol 2020; 33:417-430. [PMID: 32065354 PMCID: PMC7220980 DOI: 10.1007/s40620-020-00707-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 01/24/2020] [Indexed: 12/19/2022]
Abstract
Chronic kidney disease (CKD) represents a major public health issue worldwide and entails a high burden of cardiovascular events and mortality. Dyslipidaemia is common in patients with CKD and it is characterized by a highly atherogenic profile with relatively low levels of HDL-cholesterol and high levels of triglyceride and oxidized LDL-cholesterol. Overall, current literature indicates that lowering LDL-cholesterol is beneficial for preventing major atherosclerotic events in patients with CKD and in kidney transplant recipients while the evidence is less clear in patients on dialysis. Lipid lowering treatment is recommended in all patients with stage 3 CKD or worse, independently of baseline LDL-cholesterol levels. Statin and ezetimibe are the cornerstones in the management of dyslipidaemia in patients with CKD, however alternative and emerging lipid-lowering therapies may acquire a central role in near future. This position paper endorsed by the Italian Society of Nephrology aims at providing useful information on the topic of dyslipidaemia in CKD and at assisting decision making in the management of these patients.
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Affiliation(s)
- Roberto Pontremoli
- Università degli Studi and I.R.C.C.S. Ospedale Policlinico San Martino, Viale Benedetto XV 6, 16132, Genoa, Italy.
| | - Vincenzo Bellizzi
- Division of Nephrology, Dialysis and Transplantation, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Via San Leonardo, 84131, Salerno, Italy
| | - Stefano Bianchi
- Nephrology and Dialysis Complex Operative Unit, Department of Internal Medicine, ASL Toscana Nordovest, Livorno, Italy
| | - Roberto Bigazzi
- Nephrology and Dialysis Complex Operative Unit, Department of Internal Medicine, ASL Toscana Nordovest, Livorno, Italy
| | - Valeria Cernaro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Via Consolare Valeria 1, 98125, Messina, Italy
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, A. Manzoni Hospital, ASST Lecco, Lecco, Italy
| | - Luca De Nicola
- Nephrology Division, Department of Advanced Medical and Surgical Sciences, University of Campania "L. Vanvitelli", Piazza Miraglia, 80138, Naples, Italy
| | - Giovanna Leoncini
- Università degli Studi and I.R.C.C.S. Ospedale Policlinico San Martino, Viale Benedetto XV 6, 16132, Genoa, Italy
| | - Francesca Mallamaci
- Nephrology, Dialysis and Transplantation Unit, Ospedali Riuniti, Reggio Calabria, Italy.,CNR-IFC, Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension, Nefrologia-Ospedali Riuniti, 89100, Reggio Calabria, Italy
| | - Carmine Zoccali
- Nephrology, Dialysis and Transplantation Unit, Ospedali Riuniti, Reggio Calabria, Italy
| | - Michele Buemi
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Via Consolare Valeria 1, 98125, Messina, Italy
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Tuñón J, Badimón L, Bochaton-Piallat ML, Cariou B, Daemen MJ, Egido J, Evans PC, Hoefer IE, Ketelhuth DFJ, Lutgens E, Matter CM, Monaco C, Steffens S, Stroes E, Vindis C, Weber C, Bäck M. Identifying the anti-inflammatory response to lipid lowering therapy: a position paper from the working group on atherosclerosis and vascular biology of the European Society of Cardiology. Cardiovasc Res 2019; 115:10-19. [PMID: 30534957 PMCID: PMC6302260 DOI: 10.1093/cvr/cvy293] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 09/21/2018] [Accepted: 12/04/2018] [Indexed: 12/14/2022] Open
Abstract
Dysregulated lipid metabolism induces an inflammatory and immune response leading to atherosclerosis. Conversely, inflammation may alter lipid metabolism. Recent treatment strategies in secondary prevention of atherosclerosis support beneficial effects of both anti-inflammatory and lipid-lowering therapies beyond current targets. There is a controversy about the possibility that anti-inflammatory effects of lipid-lowering therapy may be either independent or not of a decrease in low-density lipoprotein cholesterol. In this Position Paper, we critically interpret and integrate the results obtained in both experimental and clinical studies on anti-inflammatory actions of lipid-lowering therapy and the mechanisms involved. We highlight that: (i) besides decreasing cholesterol through different mechanisms, most lipid-lowering therapies share anti-inflammatory and immunomodulatory properties, and the anti-inflammatory response to lipid-lowering may be relevant to predict the effect of treatment, (ii) using surrogates for both lipid metabolism and inflammation as biomarkers or vascular inflammation imaging in future studies may contribute to a better understanding of the relative importance of different mechanisms of action, and (iii) comparative studies of further lipid lowering, anti-inflammation and a combination of both are crucial to identify effects that are specific or shared for each treatment strategy.
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Affiliation(s)
- José Tuñón
- Department of Cardiology, Fundación Jiménez Díaz, Autónoma University and CiberCV, Avenida Reyes Católicos 2, Madrid, Spain
| | - Lina Badimón
- Cardiovascular Sciences Institute (ICCC) and CiberCV, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Bertrand Cariou
- L’Institut du Thorax, INSERM, CNRS, UNIV Nantes, CHU Nantes, Nantes, France
| | - Mat J Daemen
- Academic Medical Center, Amsterdam, The Netherlands
| | - Jesus Egido
- Fundación Jiménez Díaz, Autónoma University and CIBERDEM, Madrid, Spain
| | | | - Imo E Hoefer
- University Medical Centre Utrecht, Utrecht, Netherlands
| | | | - Esther Lutgens
- Academic Medical Center, Amsterdam, The Netherlands
- University of Amsterdam, Amsterdam, The Netherlands
- Ludwig-Maximilians-University, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Christian M Matter
- University Heart Center, University Hospital Zurich, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Claudia Monaco
- Kennedy Institute, NDORMS, University of Oxford, Oxford, UK
| | - Sabine Steffens
- Ludwig-Maximilians-University, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | | | - Cécile Vindis
- INSERM UMR-1048, Institute of Metabolic and Cardiovascular Diseases, Toulouse, France
| | - Christian Weber
- Ludwig-Maximilians-University, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Magnus Bäck
- Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital, Stockholm, Sweden
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Abstract
There is a lack of studies assessing if race impacts the efficacy of 3-hydroxy-3-methyl-glutaryl-CoA reductase (HMGCR) inhibitor ("statin") therapy on renal transplantation (RTx) outcomes. We examined the association between statin therapy and RTx outcomes, while concurrently quantifying the effect modification African American (AA) race has on statin efficacy.This was a retrospective longitudinal cohort study of solitary adult RTx (n = 1176) between June 2005 and May 2013. The Cox proportional hazard model was used to examine the impact of statin therapy on graft loss, death, and acute rejection and determine if significant interactions exist between statin therapy and race. Models were adjusted for demographics, socioeconomic status, cardiovascular history, medication use, and transplant characteristics.AAs (n = 624) and non-African Americans (n = 552) were equally likely to receive statin therapy (P = 0.922). Mean LDL and TGs in AA were 94 mg/dL and 133 mg/dL compared to 90 mg/dL and 163 mg/dL in non-AA, respectively. After adjusting for confounders, high statin users had 52% lower risk of developing graft loss (HR 0.48, 95% CI 0.29-0.80) and a nonstatistically significant reduction in death (HR 0.50, 95% CI 0.23-1.06) compared to low statin users. Acute rejection was not significantly influenced by statin use (HR 0.77 95% CI 0.46-1.27). There was a significant interaction between race and statin therapy for death (P = 0.007), but not for graft loss (P = 0.121) or rejection (P = 0.605). After stratifying by race, high statin use reduced the risk of death in AAs (HR 0.43, 95% CI 0.20-0.94), but not in non-AAs (HR 1.09, 95% CI 0.49-2.44).High statin use reduces the risk of graft loss in RTx, with a mortality benefit in AAs compared to non-AA, despite similar LDL levels. These results suggest a compelling reason to optimize statin therapy in renal transplant recipients (RTR), especially in AAs.
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Affiliation(s)
- Mukoso N Ozieh
- From the Division of Nephrology, Medical University of South Carolina, Charleston, SC; Center for Health Disparities Research, Division of General Internal Medicine, Medical University of South Carolina, Charleston, SC (MNO); Division of Transplant Surgery, Medical University of South Carolina, Charleston, SC; Department of Pharmacy, Ralph H Johnson VAMC, Charleston, SC (DJT); Center for Health Disparities Research, Division of General Internal Medicine, Medical University of South Carolina, Charleston, SC; and Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson VAMC, Charleston, SC (LEE)
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Chandra KS, Bansal M, Nair T, Iyengar SS, Gupta R, Manchanda SC, Mohanan PP, Rao VD, Manjunath CN, Sawhney JPS, Sinha N, Pancholia AK, Mishra S, Kasliwal RR, Kumar S, Krishnan U, Kalra S, Misra A, Shrivastava U, Gulati S. Consensus statement on management of dyslipidemia in Indian subjects. Indian Heart J 2014; 66 Suppl 3:S1-51. [PMID: 25595144 PMCID: PMC4297876 DOI: 10.1016/j.ihj.2014.12.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- K Sarat Chandra
- Editor, Indian Heart Journal, Sr. Cardiologist, Indo US Superspeciality Hospital, Ameerpet, Hyderabad 500016, India
| | - Manish Bansal
- Senior Consultant e Cardiology, Medanta e The Medicity, Sector 38, Gurgaon, Haryana 122001, India
| | - Tiny Nair
- Head, Department of Cardiology, PRS Hospital, Trivandrum, Akashdeep, TC 17/881, Poojapura, Trivandrum, Kerala 695012, India
| | - S S Iyengar
- Sr. Consultant & HOD, Manipal Hospital, 133, JalaVayu Towers, NGEF Layout, Indira Nagar, Bangalore 560038, India
| | - Rajeev Gupta
- Head of Medicine and Director Research, Fortis Escorts Hospital, JLN Marg, Malviya Nagar, Jaipur 302017, India
| | | | - P P Mohanan
- Westfort H. Hospital, Poonkunnanm, Thrissur 680002, India
| | - V Dayasagar Rao
- Sr. Cardiologist, Krishna Institute of Medical Science, Minister Road, Secunderabad, India
| | - C N Manjunath
- Director, Prof & HOD, Sri Jayadeva Institute of Cardiovascular Sciences & Research, Bannerghatta Road, Bangalore 560 069, India
| | - J P S Sawhney
- MD DM FACC, Chairman Department of Cardiology, Sir Ganga Ram Hospital, New Delhi, India
| | - Nakul Sinha
- Sr. Consultant & Chief Interventional Cardiologist, Sahara India Medical Institute, VirajKhand, Gomti Nagar, Lucknow, Uttar Pradesh 226010, India
| | - A K Pancholia
- Head, Department of Clinical and Preventive Cardiology and Research Centre Arihant Hospital, Indore, MP, India
| | - Sundeep Mishra
- Prof. of Cardiology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Ravi R Kasliwal
- Chairman, Clinical and Preventive Cardiology, Medanta e The Medicity, Sector 38, Gurgaon, Haryana 122001, India
| | - Saumitra Kumar
- Professor, Vivekanada Institute of Medical Sciences, Kolkata, India; Chief Co-ordinator, Academic Services (Cardiology), Narayana Hrudayalay, RTIICS, Kolkata, India; Consultant Cardiologist, Fortis Hospital, Kolkata, India
| | - Unni Krishnan
- Chief Endocrinologist & CEO, Chellaram Diabetes Institute, Pune 411021, India
| | - Sanjay Kalra
- Consultant Endocrinology, Bharti Hospital & BRIDE, Karnal, Haryana, India
| | - Anoop Misra
- Chairman, Fortis-C-DOC Centre of Excellence for Diabetes, Metabolic Diseases and Endocrinology, Chirag Enclave, New Delhi, India
| | - Usha Shrivastava
- Head, Public Health, National Diabetes, Obesity and Cholesterol Foundation (N-DOC), Diabetes Foundation (India), New Delhi, India
| | - Seema Gulati
- Head, Nutrition Research Group, Center for Nutrition & Metabolic Research (C-NET) & National Diabetes, Obesity and Cholesterol Foundation (N-DOC), New Delhi, India; Chief Project Officer, Diabetes Foundation (India), C-6/57, Safdarjung Development Area, New Delhi 110 016, India
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Palmer SC, Navaneethan SD, Craig JC, Perkovic V, Johnson DW, Nigwekar SU, Hegbrant J, Strippoli GFM. HMG CoA reductase inhibitors (statins) for kidney transplant recipients. Cochrane Database Syst Rev 2014; 2014:CD005019. [PMID: 24470059 PMCID: PMC8860132 DOI: 10.1002/14651858.cd005019.pub4] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND People with chronic kidney disease (CKD) have higher risks of cardiovascular disease compared to the general population. Specifically, cardiovascular deaths account most deaths in kidney transplant recipients. Statins are a potentially beneficial intervention for kidney transplant patients given their established benefits in patients at risk of cardiovascular disease in the general population. This is an update of a review first published in 2009. OBJECTIVES We aimed to evaluate the benefits (reductions in all-cause and cardiovascular mortality, major cardiovascular events, myocardial infarction and stroke, and progression of CKD to requiring dialysis) and harms (muscle or liver dysfunction, withdrawal, cancer) of statins compared to placebo, no treatment, standard care, or another statin in adults with CKD who have a functioning kidney transplant. SEARCH METHODS We searched the Cochrane Renal Group's Specialised Register to 29 February 2012 through contact with the Trials Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs that compared the effects of statins with placebo, no treatment, standard care, or statins on mortality, cardiovascular events, kidney function and toxicity in kidney transplant recipients. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed risk of bias. Treatment effects were expressed as mean difference (MD) for continuous outcomes (lipids, glomerular filtration rate (GFR), proteinuria) and relative risk (RR) for dichotomous outcomes (major cardiovascular events, mortality, fatal or non-fatal myocardial infarction, fatal or non-fatal stroke, elevated muscle or liver enzymes, withdrawal due to adverse events, cancer, end-stage kidney disease (ESKD), acute allograft rejection) together with 95% confidence intervals (CI). MAIN RESULTS We identified 22 studies (3465 participants); 17 studies (3282 participants) compared statin with placebo or no treatment, and five studies (183 participants) compared two different statin regimens.From data generally derived from a single high-quality study, it was found that statins may reduce major cardiovascular events (1 study, 2102 participants: RR 0.84, CI 0.66 to 1.06), cardiovascular mortality (4 studies, 2322 participants: RR 0.68, CI 0.45 to 1.01), and fatal or non-fatal myocardial infarction (1 study, 2102 participants: RR 0.70, CI 0.48 to 1.01); although effect estimates lack precision and include the possibility of no effect.Statins had uncertain effects on all-cause mortality (6 studies, 2760 participants: RR 1.08, CI 0.63 to 1.83); fatal or non-fatal stroke (1 study, 2102 participants: RR 1.18, CI 0.85 to 1.63); creatine kinase elevation (3 studies, 2233 participants: RR 0.86, CI 0.39 to 1.89); liver enzyme elevation (4 studies, 608 participants: RR 0.62, CI 0.33 to 1.19); withdrawal due to adverse events (9 studies, 2810 participants: RR 0.89, CI 0.74 to 1.06); and cancer (1 study, 2094 participants: RR 0.94, CI 0.82 to 1.07).Statins significantly reduced serum total cholesterol (12 studies, 3070 participants: MD -42.43 mg/dL, CI -51.22 to -33.65); low-density lipoprotein cholesterol (11 studies, 3004 participants: MD -43.19 mg/dL, CI -52.59 to -33.78); serum triglycerides (11 studies, 3012 participants: MD -27.28 mg/dL, CI -34.29 to -20.27); and lowered high-density lipoprotein cholesterol (11 studies, 3005 participants: MD -5.69 mg/dL, CI -10.35 to -1.03).Statins had uncertain effects on kidney function: ESKD (6 studies, 2740 participants: RR 1.14, CI 0.94 to 1.37); proteinuria (2 studies, 136 participants: MD -0.04 g/24 h, CI -0.17 to 0.25); acute allograft rejection (4 studies, 582 participants: RR 0.88, CI 0.61 to 1.28); and GFR (1 study, 62 participants: MD -1.00 mL/min, CI -9.96 to 7.96).Due to heterogeneity in comparisons, data directly comparing differing statin regimens could not be meta-analysed. Evidence for statins in people who have had a kidney transplant were sparse and lower quality due to imprecise effect estimates and provided limited systematic evaluation of treatment harm. AUTHORS' CONCLUSIONS Statins may reduce cardiovascular events in kidney transplant recipients, although treatment effects are imprecise. Statin treatment has uncertain effects on overall mortality, stroke, kidney function, and toxicity outcomes in kidney transplant recipients. Additional studies would improve our confidence in the treatment benefits and harms of statins on cardiovascular events in this clinical setting.
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Affiliation(s)
- Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Sankar D Navaneethan
- Glickman Urological and Kidney Institute, Cleveland ClinicDepartment of Nephrology and HypertensionClevelandOHUSA44195
| | - Jonathan C Craig
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - Vlado Perkovic
- The George Institute for International HealthRenal and Metabolic DivisionCamperdownNSWAustralia
| | - David W Johnson
- Princess Alexandra HospitalDepartment of NephrologyIpswich RdWoolloongabbaQueenslandAustralia4102
| | - Sagar U Nigwekar
- Harvard Medical SchoolBrigham and Women's Hospital, Massachusetts General Hospital, Scholars in Clinical Sciences ProgramBostonMAUSA
| | - Jorgen Hegbrant
- Diaverum Renal Services GroupMedical OfficePO Box 4167LundSwedenSE‐227 22
| | - Giovanni FM Strippoli
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchWestmeadNSWAustralia2145
- Mario Negri Sud FoundationClinical Pharmacology and EpidemiologySanta Maria ImbaroItaly
- Amedeo Avogadro University of Eastern PiedmontNovaraItaly
- DiaverumMedical Scientific OfficeLundSweden
- Diaverum AcademyBariItaly
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Palmer SC, Craig JC, Navaneethan SD, Tonelli M, Pellegrini F, Strippoli GFM. Benefits and harms of statin therapy for persons with chronic kidney disease: a systematic review and meta-analysis. Ann Intern Med 2012; 157:263-75. [PMID: 22910937 PMCID: PMC3955032 DOI: 10.7326/0003-4819-157-4-201208210-00007] [Citation(s) in RCA: 241] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Statins have uncertain benefits in persons with chronic kidney disease (CKD) because individual trials may have insufficient power to determine whether treatment effects differ with severity of CKD. PURPOSE To summarize the benefits and harms of statin therapy for adults with CKD and examine whether effects of statins vary by stage of kidney disease. DATA SOURCES Cochrane and EMBASE databases (inception to February 2012). STUDY SELECTION Randomized trials comparing the effects of statins with placebo, no treatment, or another statin on mortality and cardiovascular outcomes. DATA EXTRACTION Two independent reviewers extracted data and assessed risk of bias. DATA SYNTHESIS Eighty trials comprising 51099 participants compared statin with placebo or no treatment. Treatment effects varied with stage of CKD. Moderate- to high-quality evidence indicated that statins reduced all-cause mortality (relative risk [RR], 0.81 [95% CI, 0.74 to 0.88]), cardiovascular mortality (RR, 0.78 [CI, 0.68 to 0.89]), and cardiovascular events (RR, 0.76 [CI, 0.73 to 0.80]) in persons not receiving dialysis. Moderate- to high-quality evidence indicated that statins had little or no effect on all-cause mortality (RR, 0.96 [CI, 0.88 to 1.04]), cardiovascular mortality (RR, 0.94 [CI, 0.82 to 1.07]), or cardiovascular events (RR, 0.95 [CI, 0.87 to 1.03]) in persons receiving dialysis. Effects of statins in kidney transplant recipients were uncertain. Statins had little or no effect on cancer, myalgia, liver function, or withdrawal from treatment, although adverse events were evaluated systematically in fewer than half of the trials. LIMITATION There was a reliance on post hoc subgroup data for earlier stages of CKD. CONCLUSION Statins decrease mortality and cardiovascular events in persons with early stages of CKD, have little or no effect in persons receiving dialysis, and have uncertain effects in kidney transplant recipients.
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Affiliation(s)
- Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
- Cochrane Renal Group, Sydney, Australia
| | - Jonathan C Craig
- Cochrane Renal Group, Sydney, Australia
- School of Public Health, University of Sydney, Sydney, Australia
| | - Sankar D Navaneethan
- Cochrane Renal Group, Sydney, Australia
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, USA
| | - Marcello Tonelli
- Cochrane Renal Group, Sydney, Australia
- Division of Nephrology and Immunology, University of Alberta, Edmonton, Canada
| | - Fabio Pellegrini
- Consorzio Mario Negri Sud, S. Maria Imbaro, Italy
- Scientific Institute Casa Sollievo della Sofferenza, Italy
| | - Giovanni FM Strippoli
- Cochrane Renal Group, Sydney, Australia
- School of Public Health, University of Sydney, Sydney, Australia
- Consorzio Mario Negri Sud, S. Maria Imbaro, Italy
- Diaverum Scientific Medical Office, Lund, Sweden
- Department of Emergency and Organ Transplantation, University of Bari, Italy
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Lentine KL, Costa SP, Weir MR, Robb JF, Fleisher LA, Kasiske BL, Carithers RL, Ragosta M, Bolton K, Auerbach AD, Eagle KA. Cardiac disease evaluation and management among kidney and liver transplantation candidates: a scientific statement from the American Heart Association and the American College of Cardiology Foundation. J Am Coll Cardiol 2012; 60:434-80. [PMID: 22763103 DOI: 10.1016/j.jacc.2012.05.008] [Citation(s) in RCA: 254] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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8
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Lentine KL, Costa SP, Weir MR, Robb JF, Fleisher LA, Kasiske BL, Carithers RL, Ragosta M, Bolton K, Auerbach AD, Eagle KA. Cardiac disease evaluation and management among kidney and liver transplantation candidates: a scientific statement from the American Heart Association and the American College of Cardiology Foundation: endorsed by the American Society of Transplant Surgeons, American Society of Transplantation, and National Kidney Foundation. Circulation 2012; 126:617-63. [PMID: 22753303 DOI: 10.1161/cir.0b013e31823eb07a] [Citation(s) in RCA: 183] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Guillén D, Cofán F, Ros E, Millán O, Cofán M, Brunet M. Biomarker assessment of the immunomodulator effect of atorvastatin in stable renal transplant recipients and hypercholesterolemic patients. Mol Diagn Ther 2011. [PMID: 21047146 DOI: 10.2165/11539620-000000000-00000] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND HMG-CoA reductase inhibitors (statins) have effects beyond lipid lowering, including immunomodulatory and anti-inflammatory properties. Statins are frequently combined with immunosuppressive agents in transplant recipients to modulate the hyperlipidemic side effects of the immunosuppressants. However, the role of statins in the immunosuppressive response that is achieved in individual patients remains to be assessed. OBJECTIVE The aim of this study was to evaluate the immunomodulatory effect of atorvastatin given alone and in combined treatment with tacrolimus and mycophenolate mofetil. STUDY DESIGN Two patient groups were studied: renal transplant recipients receiving tacrolimus and mycophenolate mofetil therapy, and hypercholesterolemic patients (the control group). Fasting blood samples were taken from participants before and 1 month after atorvastatin treatment was started to study a small battery of biomarkers that are able to reflect the range of the effects of immunosuppressive therapy and atorvastatin. SETTING All patients in the study were enrolled at the Hospital Clinic of Barcelona. PATIENTS All patients enrolled in the study were candidates for treatment with atorvastatin because of high cholesterol levels. One group consisted of 25 stable renal transplant recipients with low-density lipoprotein (LDL) cholesterol levels above 100 mg/dL after 3 months of therapeutic lifestyle changes, according to the guidelines of the National Kidney Foundation - Kidney Disease Outcomes Quality Initiative. The other group included 25 hypercholesterolemic patients with LDL cholesterol levels above target values for the patients' overall risk, as derived from the National Cholesterol Education Program Adult Treatment Panel III criteria. INTERVENTION Atorvastatin (Lipitor®) treatment was started at a fixed dose of 20 mg daily. MAIN OUTCOME MEASURE The studied biomarkers were lymphocyte proliferation, intracellular adenosine triphosphate (ATP) synthesis in CD4+ T cells, intralymphocytary cytokine expression (interleukin [IL]-2, interferon [IFN]-γ), soluble cytokine production (IL-2, IFN-γ, IL-10, IL-17, and transforming growth factor-β) and regulatory T (T(reg)) cells. RESULTS Atorvastatin proved to be an immunomodulatory agent, significantly decreasing lymphocyte proliferation by 15% (p = 0.001), increasing ATP levels by 16% (p = 0.0004), and showing a trend toward increasing T(reg) cells in hypercholesterolemic patients (p = 0.09). In the renal transplant recipients, atorvastatin therapy did not modify any of the biomarkers of immunosuppression that were studied. CONCLUSION Atorvastatin showed immunoregulatory effects on T cells in hypercholesterolemic patients. These effects were absent in renal transplant recipients, suggesting that the beneficial effects of atorvastatin in this patient group do not relate to immunoregulation. Therefore, statin treatment cannot be considered as a means to reduce the dose of immunosuppressive agents.
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Affiliation(s)
- David Guillén
- Pharmacology Laboratory (Biomedical Diagnosis Center), Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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10
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Biomarker assessment of the immunomodulator effect of atorvastatin in stable renal transplant recipients and hypercholesterolemic patients. Mol Diagn Ther 2011; 14:357-66. [PMID: 21047146 DOI: 10.1007/bf03256393] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND HMG-CoA reductase inhibitors (statins) have effects beyond lipid lowering, including immunomodulatory and anti-inflammatory properties. Statins are frequently combined with immunosuppressive agents in transplant recipients to modulate the hyperlipidemic side effects of the immunosuppressants. However, the role of statins in the immunosuppressive response that is achieved in individual patients remains to be assessed. OBJECTIVE The aim of this study was to evaluate the immunomodulatory effect of atorvastatin given alone and in combined treatment with tacrolimus and mycophenolate mofetil. STUDY DESIGN Two patient groups were studied: renal transplant recipients receiving tacrolimus and mycophenolate mofetil therapy, and hypercholesterolemic patients (the control group). Fasting blood samples were taken from participants before and 1 month after atorvastatin treatment was started to study a small battery of biomarkers that are able to reflect the range of the effects of immunosuppressive therapy and atorvastatin. SETTING All patients in the study were enrolled at the Hospital Clinic of Barcelona. PATIENTS All patients enrolled in the study were candidates for treatment with atorvastatin because of high cholesterol levels. One group consisted of 25 stable renal transplant recipients with low-density lipoprotein (LDL) cholesterol levels above 100 mg/dL after 3 months of therapeutic lifestyle changes, according to the guidelines of the National Kidney Foundation - Kidney Disease Outcomes Quality Initiative. The other group included 25 hypercholesterolemic patients with LDL cholesterol levels above target values for the patients' overall risk, as derived from the National Cholesterol Education Program Adult Treatment Panel III criteria. INTERVENTION Atorvastatin (Lipitor®) treatment was started at a fixed dose of 20 mg daily. MAIN OUTCOME MEASURE The studied biomarkers were lymphocyte proliferation, intracellular adenosine triphosphate (ATP) synthesis in CD4+ T cells, intralymphocytary cytokine expression (interleukin [IL]-2, interferon [IFN]-γ), soluble cytokine production (IL-2, IFN-γ, IL-10, IL-17, and transforming growth factor-β) and regulatory T (T(reg)) cells. RESULTS Atorvastatin proved to be an immunomodulatory agent, significantly decreasing lymphocyte proliferation by 15% (p = 0.001), increasing ATP levels by 16% (p = 0.0004), and showing a trend toward increasing T(reg) cells in hypercholesterolemic patients (p = 0.09). In the renal transplant recipients, atorvastatin therapy did not modify any of the biomarkers of immunosuppression that were studied. CONCLUSION Atorvastatin showed immunoregulatory effects on T cells in hypercholesterolemic patients. These effects were absent in renal transplant recipients, suggesting that the beneficial effects of atorvastatin in this patient group do not relate to immunoregulation. Therefore, statin treatment cannot be considered as a means to reduce the dose of immunosuppressive agents.
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Impact of statins on cardiovascular outcomes in renal transplant recipients: a systematic review. Am J Ther 2010; 18:e48-54. [PMID: 21048435 DOI: 10.1097/mjt.0b013e3181cec203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Patients with chronic kidney disease including renal transplant recipients (RTRs) have a markedly higher prevalence of cardiovascular disease than the general population. Many trials have established the role of statins in the prevention of cardiovascular mortality, not only by decreasing the low density lipoprotein-cholesterol levels but also by their pleotropic effects. These data from the general population may not be applicable to RTRs as these patients have different cardiovascular risk profiles. Till date, only a few prospective, randomized trials have assessed the use of statins in RTRs with regards to cardiovascular outcomes. The Assessment of Lescol in Renal Transplant trial, the largest trial so far, suggested that dyslipidemia management with statins in RTRs is associated with a significant reduction in the incidence of cardiac death and nonfatal myocardial infarction (although differences in the combined primary end point were not statistically significant). The current guidelines from National Kidney Foundation for managing dyslipidemia in RTRs recommend managing all chronic kidney disease patients as a coronary heart disease equivalent. The task group for drafting these guidelines concluded that based on the currently available evidence, additional studies may be needed in RTRs to confirm and extend the results of Assessment of Lescol in Renal Transplant trial.
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Younas N, Wu CM, Shapiro R, McCauley J, Johnston J, Tan H, Basu A, Schaefer H, Smetanka C, Winkelmayer WC, Unruh M. HMG-CoA reductase inhibitors in kidney transplant recipients receiving tacrolimus: statins not associated with improved patient or graft survival. BMC Nephrol 2010; 11:5. [PMID: 20359353 PMCID: PMC2855559 DOI: 10.1186/1471-2369-11-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Accepted: 04/01/2010] [Indexed: 11/21/2022] Open
Abstract
Background The beneficial effects of early statin use in kidney transplant recipients, especially those on tacrolimus-based immunosuppression, are not well established. We evaluated the predictors of statin use following kidney transplantation and examined its association with patient and allograft survival. Methods We examined 615 consecutive patients who underwent kidney transplant at our institution between January 1998 and January 2002. Statin use was assessed at baseline and 3, 6, 9, and 12 months following kidney transplant. Patients were followed for allograft and patient survival. Results 36% of the 615 kidney transplant recipients were treated with statin treatment. Statin use increased over the course of the study period. Older age, elevated body mass index, higher triglyceride levels, hypercholesterolemia, diabetes, history of myocardial infarction were associated with higher rates of statin use; elevated alkaline phosphatase levels and CMV IgG seropositivity were associated with less statin use. Older age, elevated BMI and hypercholesterolemia remained significant predictors of increased statin use after accounting for covariates using multiple regression. The early use of statins was not associated with improvements in unadjusted patient survival [HR 0.99; 95%CI 0.72-1.37] or graft survival [HR 0.97; 95% CI 0.76-1.24]. The risks of death and graft survival were not consistently reduced with exposure to statin using either adjusted models or propensity scores in Cox Proportional Hazards models. Conclusions In a kidney transplant population primarily receiving tacrolimus-based immunosuppression, early statin use was not associated with significantly improved graft or patient survival.
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Affiliation(s)
- Nizar Younas
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, PA, USA
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Navaneethan SD, Perkovic V, Johnson DW, Nigwekar SU, Craig JC, Strippoli GFM. HMG CoA reductase inhibitors (statins) for kidney transplant recipients. Cochrane Database Syst Rev 2009:CD005019. [PMID: 19370615 DOI: 10.1002/14651858.cd005019.pub3] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Cardiovascular deaths account for the majority of deaths in kidney transplant recipients and dyslipidaemia contributes significantly to their cardiovascular disease. Statins are widely used in kidney transplant patients given their established benefits in the general population, however evidence favouring their use is lacking. OBJECTIVES To assess the benefits and harms of statin therapy on mortality and renal outcomes in kidney transplant recipients. SEARCH STRATEGY We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and hand searched reference lists of articles and scientific proceedings. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing statins with placebo, no treatment or other statins in kidney transplant recipients. DATA COLLECTION AND ANALYSIS Two authors independently assessed study quality and extracted data. Statistical analyses were performed using the random effects model after testing for heterogeneity. Results were expressed as mean difference (MD) for continuous outcomes (lipid parameters) and risk ratio (RR) for dichotomous outcomes (mortality, allograft rejection, liver enzymes, occurrence of rhabdomyolysis and study withdrawal) with 95% confidence intervals (CI). MAIN RESULTS Sixteen studies (3229 patients) comparing statins versus placebo (15) or another statin (1) were included. Compared to placebo, statins did not decrease all-cause mortality (14 studies: RR 1.30, 95% CI 0.54 to 3.12). Point estimates favoured statins in terms of cardiovascular mortality (13 studies: RR 0.68, 95% CI 0.46 to 1.03) and non-fatal cardiovascular events (1 study: RR 0.70, 95% CI 0.48 to 1.01), however the results were not statistically significant. Compared to placebo, the use of statins was associated with a significantly lower end of treatment average total cholesterol (10 studies: MD -42.33 mg/dL (1.26 mmol/L), 95% CI -53.02 to -31.64), LDL cholesterol (10 studies: MD -46.15 mg/dL (1.19 mmol/L), 95% CI -55.97 to -36.33) and triglycerides (10 studies: MD -25.46 mg/dL (0.26 mmol/L), 95% CI -33.95 to 16.9). There was no significant difference in the risk of acute rejection (5 studies: RR 0.61; 95% C.I.0.32 to 1.16.) No data on chronic rejection was available and no major toxicity was noted. AUTHORS' CONCLUSIONS Statins significantly reduced hyperlipidaemia and tended to reduce cardiovascular events in kidney transplant recipients, but no effect has yet been demonstrated for mortality outcomes. Most of the data was derived from one large long-term study. Considering the significant impact of statins on all-cause and cardiovascular mortality in the general and predialysis populations, more studies are needed in kidney transplant patients.
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Affiliation(s)
- Sankar D Navaneethan
- Department of Nephrology and Hypertension, Glickman Urological and Kidney institute, Cleveland Clinic, Cleveland, OH 44195, USA.
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Wiesbauer F, Heinze G, Mitterbauer C, Harnoncourt F, Hörl WH, Oberbauer R. Statin use is associated with prolonged survival of renal transplant recipients. J Am Soc Nephrol 2008; 19:2211-8. [PMID: 18650477 DOI: 10.1681/asn.2008010101] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The efficacy of statins for the prevention of cardiovascular events is well established in the general population but remains unknown in renal transplant recipients. In this study, the association of statin use with patient and graft survival was investigated in a cohort of 2041 first-time recipients of renal allografts between 1990 and 2003. Multivariable Cox regression demonstrated that statin use was independently associated with lower mortality rates. Twelve-year survival rates were 73% for statin users and 64% for nonusers (P = 0.055). The adjusted hazard ratio for all-cause mortality associated with statin use was 0.64 (95% confidence interval 0.48 to 0.86). Graft survival rates during the same time period were 76% for statin users and 70% for nonusers (P = 0.055). The adjusted hazard ratio for graft survival associated with statin use was 0.76 (95% confidence interval 0.55 to 1.04). Results from marginal structural models were virtually identical. In summary, statin use was associated with prolonged patient survival, but no difference in graft survival was detected. Although these results are encouraging, a definitive causal relationship can be determined only from randomized clinical trials.
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Affiliation(s)
- Franz Wiesbauer
- Department of Cardiology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
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Steffens S, Mach F. Drug Insight: immunomodulatory effects of statins—potential benefits for renal patients? ACTA ACUST UNITED AC 2006; 2:378-87. [PMID: 16932466 DOI: 10.1038/ncpneph0217] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2005] [Accepted: 03/17/2006] [Indexed: 01/24/2023]
Abstract
Statins inhibit 3-hydroxyl-3-methylglutaryl coenzyme A reductase, an enzyme crucial to cholesterol synthesis. Drugs of this class reduce the risk of coronary heart disease and stroke, in large part through lipid modulation. Emerging evidence indicates that statins have additional modes of action. These actions, which encompass modification of endothelial function, plaque stability, thrombus formation and inflammatory pathways, are widely referred to as 'pleiotropic effects'. These pleiotropic effects indicate that the therapeutic potential of statins might extend beyond cholesterol lowering and cardiovascular disease to other inflammatory disorders or conditions such as transplantation, multiple sclerosis, rheumatoid arthritis and chronic kidney disease. Experimental and clinical data provide evidence to support these broader applications of statins; however, more large-scale trials are needed to clarify the therapeutic benefit.
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Affiliation(s)
- Sabine Steffens
- Division of Cardiology, Department of Medicine, University Hospital, Foundation for Medical Research, Geneva, Switzerland
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Almuti K, Rimawi R, Spevack D, Ostfeld RJ. Effects of statins beyond lipid lowering: Potential for clinical benefits. Int J Cardiol 2006; 109:7-15. [PMID: 16054715 DOI: 10.1016/j.ijcard.2005.05.056] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2005] [Accepted: 05/21/2005] [Indexed: 02/06/2023]
Abstract
BACKGROUND The role of statin drugs in the reduction of serum lipids has been well documented. More recently, evidence suggesting that statins may positively impact many organ systems and disease states independent of lipid reduction has emerged. The term "pleiotropic effects" has been used to refer to these properties. We reviewed the evidence exploring such potential effects. METHODS A search of the MEDLINE database was conducted for articles published between 1985 to 2005 on the pleiotropic and the lipid-lowering independent effects of statin drugs. The search terms "statin", "HMG-CoA reductase inhibitor", "pleiotropic effects", and "inflammation" were used. English language articles were selected for inclusion along with selected cross-references. RESULTS Numerous animal and clinical studies support the presence of a spectrum of beneficial effects for statins that are independent of their lipid-lowering properties. These effects are mediated by a variety of mechanisms and they suggest that the therapeutic role of statins may expand. CONCLUSION Statins have shown great promise beyond their lipid-lowering effects. Ongoing and future studies will help to further clarify the potential clinical impact of these "pleiotropic effects".
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Affiliation(s)
- Khalid Almuti
- Department of Medicine, Montefiore Medical Center, Bronx, New York, USA
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Buemi M, Nostro L, Crascì E, Barillà A, Cosentini V, Aloisi C, Sofi T, Campo S, Frisina N. Statins in nephrotic syndrome: a new weapon against tissue injury. Med Res Rev 2006; 25:587-609. [PMID: 16075407 DOI: 10.1002/med.20040] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The nephrotic syndrome is characterized by metabolic disorders leading to an increase in circulating lipoproteins levels. Hypertriglyceridemia and hypercholesterolemia in this case may depend on a reduction in triglyceride-rich lipoproteins catabolism and on an increase in hepatic synthesis of Apo B-containing lipoproteins. These alterations are the starting point of a self-maintaining mechanism, which can accelerate the progression of chronic renal failure. Indeed, hyperlipidemia can affect renal function, increase proteinuria and speed glomerulosclerosis, thus determining a higher risk of progression to dialysis. 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase is the rate-limiting enzyme in cholesterol synthesis from mevalonate and its inhibitors, or statins, can therefore interfere with the above-mentioned consequences of hyperlipidemia. Statins are already well known for their effectiveness on primary cardiovascular prevention, which cannot be explained only through their hypolipemic effect. As far as kidney diseases are concerned, statin therapy has been shown to prevent creatinine clearance decline and to slow renal function loss, particularly in case of proteinuria, and its favorable effect may depend only partially on the attenuation of hyperlipidemia. Statins may therefore confer tissue protection through lipid-independent mechanisms, which can be triggered by other mediators, such as angiotensin receptor blockers. Possible pathways for the protective action of statins, other than any hypocholesterolemic effect, are: cellular apoptosis/proliferation balance, inflammatory cytokines production, and signal transduction regulation. Statins also play a role in the regulation of the inflammatory and immune response, coagulation process, bone turnover, neovascularization, vascular tone, and arterial pressure. In this study, we would like to provide scientific evidences for the pleiotropic effects of statins, which could be the starting point for the development of new therapeutical strategies in different clinical areas.
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Affiliation(s)
- Michele Buemi
- Department of Internal Medicine, University of Messina, Messina, Italy.
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Abeles AM, Pillinger MH. Statins as antiinflammatory and immunomodulatory agents: A future in rheumatologic therapy? ACTA ACUST UNITED AC 2006; 54:393-407. [PMID: 16447216 DOI: 10.1002/art.21521] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Aryeh M Abeles
- New York University School of Medicine, the Hospital for Joint Diseases, New York, New York, USA
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Abstract
Managing the failing allograft juxtaposes immunosuppressive management and routine chronic kidney disease care. The complications of immunosuppression can be more pronounced in those with renal failure (infection, anemia, bone disease). The withdrawal of immunosuppression may be associated with acute allograft rejection, arthralgias, and the development of antidonor antibodies. Likewise depression is prevalent. Improving well-being and overall survival necessitates proper titration of immunosuppressive medications and control of blood pressure, anemia, lipids, and glucose along with attention to treatment of depression.
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Affiliation(s)
- Elizabeth A Kendrick
- Department of Medicine, Division of Nephrology, University of Washington School of Medicine, Seattle, Washington, USA
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Masterson R, Hewitson T, Leikis M, Walker R, Cohney S, Becker G. Impact of statin treatment on 1-year functional and histologic renal allograft outcome. Transplantation 2005; 80:332-8. [PMID: 16082328 DOI: 10.1097/01.tp.0000168941.19689.cf] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Statins are antilipidemic agents that exhibit a variety of cellular effects independent of their lipid-lowering action. A retrospective study was undertaken to establish the impact of statins on graft outcome in the first year posttransplantation. METHODS Data from patients with uniform immunosuppression (cyclosporine, mycophenolate mofetil, and prednisolone) who underwent transplantation at the authors' unit from 1997 to 2002 were reviewed. Patients prescribed statins were compared with those not on a statin. Mean change in creatinine clearance (CrCl) from 3 to 12 months posttransplantation was calculated. Histomorphometric analysis was used to quantify fractional interstitial area and collagen III deposition in matched preperfusion and 12-month protocol biopsy specimens. RESULTS Seventy-seven patients met study criteria: statin, n=44 patients; nonstatin, n=33 patients. Median time to commencing a statin was 5 weeks. At 3 months, CrCl (+/-SEM) was similar: 51.6+/-2.9 mL/min (statin) versus 51.3+/-1 mL/min (nonstatin). At 12 months, the mean change in CrCl was 4.1+/-1 mL/min (statin) compared with -2.0+/-1.8 mL/min (nonstatin), resulting in a difference of 6.13 mL/min at 12 months (P<0.005). Mean preperfusion fractional interstitial areas were similar (23.9+/-1.6%; P=not significant [NS]). On 12-month biopsy specimens, the fractional interstitial area had increased to 34+/-3.2% in the nonstatin group (P<0.005), with no change in the statin group. Interstitial collagen III deposition was similar in preperfusion biopsy specimens (10.4+/-1%; P=NS), but at 12 months it was significantly greater in the nonstatin group (17.6+/-1%; P<0.05) CONCLUSIONS Early introduction of statins may be associated with improved 1-year graft outcome.
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Affiliation(s)
- Rosemary Masterson
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Melbourne, Victoria, Australia.
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Abstract
OBJECTIVE Patients with chronic kidney disease (CKD) are at higher risk for cardiovascular disease (CVD) than patients in the general population. One potentially modifiable risk factor for CVD in patients with CKD is dyslipidemia. In the current manuscript we review observational and trial data assessing dyslipidemia and its treatment in this patient population. RESULTS Observational studies have noted a "reverse epidemiology" in patients with CKD such that low total cholesterol levels are associated with a higher mortality rate. The complex lipid profile of patients with CKD also raises questions as to whether lipid-lowering therapy will be beneficial in this patient population. Although there are only a few trials assessing the relationship between lipid-lowering therapy and CVD outcomes in CKD patients, many lipid-lowering medications are both safe and effective. In addition, there is suggestive evidence that statin therapy, in particular, also may reduce inflammation and slow the decline in glomerular filtration rate (GFR) in patients during the earlier stages of CKD. CONCLUSION Because of the high rate of CVD in patients with CKD and the overall safety of most medical therapies for dyslipidemia in CKD, current guidelines from the National Kidney Foundation Kidney Disease Outcomes Quality Initiative recommend aggressive therapy of dyslipidemia. These guidelines do, however, acknowledge the paucity of trial data in this patient population. There are 3 ongoing randomized controlled trials that are assessing the effect of statin therapy on CVD outcomes. These studies will hopefully provide definitive answers as to the appropriate treatment of dyslipidemia in CKD.
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Affiliation(s)
- Daniel E Weiner
- Division of Nephrology, Tufts-New England Medical Center, Boston, Massachusetts, USA
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Lentine KL, Brennan DC. Statin use after renal transplantation: a systematic quality review of trial-based evidence. Nephrol Dial Transplant 2004; 19:2378-86. [PMID: 15252155 DOI: 10.1093/ndt/gfh385] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVES HMG-CoA reductase inhibitor (statin) therapy reduces cardiovascular risk in the general population and may modulate rejection in solid organ transplant recipients. We assessed whether current clinical evidence supports the use of statins to improve cardiac and/or renal outcomes after kidney transplantation. METHODS We performed a systematic review of randomized, controlled intervention trials of statins among renal allograft recipients. Clinical trials published between January 1, 1993 and January 1, 2004 were identified by systematic search of electronic databases. Eligible studies measured the impact of therapy on acute allograft rejection, surrogates of cardiovascular risk and/or cardiovascular morbidity and mortality. We abstracted descriptive summaries of trial design elements and primary effect estimates, and assessed trial quality with a standardized quality evaluation tool. RESULTS Thirteen eligible trials were identified. Statin therapy was associated with less acute allograft rejection in two early studies but was ineffective in three subsequent, larger trials. Therapeutic benefit was also seen in six of seven small studies that evaluated cardiovascular risk surrogates. Statin use did not significantly alter the primary composite outcome in a single large cardiac events trial, but was associated with reductions in secondary end-points of cardiac death analysed alone or with myocardial infarction. Important design distinctions included statin preparation and dose, concomitant interventions, study power and randomization methods. Median total quality scores were 52 for the rejection trials, 41 for the studies of cardiovascular risk surrogates and 69 for the cardiac events trial, and showed a trend towards variation by outcome measure (P = 0.05). CONCLUSIONS Heterogeneous study designs and methodological quality contribute to discrepant conclusions on the benefit of statin therapy to renal allograft recipients. Trial-based clinical evidence does not support the use of statins to lower acute rejection risk after kidney transplantation, but does indicate effectiveness for improvement in cardiovascular risk markers and possibly for reduction of clinical cardiac events.
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Affiliation(s)
- Krista L Lentine
- Division of Nephrology, Washington University Medical Center, Campus Box 8219, 660 S. Euclid Avenue, St Louis, MO 63110, USA.
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Wilson HL, Schwartz DM, Bhatt HRF, McCulloch CE, Duncan JL. Statin and aspirin therapy are associated with decreased rates of choroidal neovascularization among patients with age-related macular degeneration. Am J Ophthalmol 2004; 137:615-24. [PMID: 15059698 DOI: 10.1016/j.ajo.2003.10.025] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2003] [Indexed: 11/25/2022]
Abstract
PURPOSE To investigate the relationship between statin and aspirin use and the risk of choroidal neovascularization (CNV) in patients with age-related macular degeneration (AMD). DESIGN Retrospective consecutive case series. METHODS All patients 60 years and older with AMD who were seen between January 1, 1990, and March 1, 2003, at the San Francisco Veterans Affairs Hospital Eye Clinic with fundus photographs were included. Patients with other diagnoses predisposing to CNV or incomplete medical records were excluded. The main outcome measure was angiographically evident CNV. Diagnosis was based on review of fundus photographs and fluorescein angiograms in masked fashion; medical records were reviewed for variables possibly predisposing to CNV or statin use. For patients with CNV, age of onset was recorded; those without CNV were treated as censored. Age-related macular degeneration disease status and time of onset of CNV was compared between patients treated or not treated with statins for at least 6 months. RESULTS Of 326 patients with AMD, 104 had CNV, 204 had dry AMD, and 18 had geographic atrophy (GA). Of CNV subjects, 21 (20%) used statins, compared with 77 (38%) of dry AMD subjects without GA and 6 (33%) of controls with GA (hazard ratio = 0.51, 95% confidence interval (CI) = 0.31-0.86, P =.01). Aspirin use was also significantly associated with decreased rates of CNV; 62 CNV subjects (60%) used aspirin, compared with 154 (75%) dry AMD subjects without GA or 12 (67%) with GA (hazard ratio = 0.63, 95% CI = 0.40-0.98, P =.04). CONCLUSIONS Therapy with statins or aspirin is associated with decreased rates of CNV among AMD patients. Additional study with a prospective and/or randomized trial of statin and aspirin use in AMD patients is warranted.
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Affiliation(s)
- Hilary L Wilson
- Department of Ophthalmology, UCSF School of Medicine, San Francisco, CA 94143, USA
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Kasiske B, Cosio FG, Beto J, Bolton K, Chavers BM, Grimm R, Levin A, Masri B, Parekh R, Wanner C, Wheeler DC, Wilson PWF. Clinical practice guidelines for managing dyslipidemias in kidney transplant patients: a report from the Managing Dyslipidemias in Chronic Kidney Disease Work Group of the National Kidney Foundation Kidney Disease Outcomes Quality Initiative. Am J Transplant 2004; 4 Suppl 7:13-53. [PMID: 15027968 DOI: 10.1111/j.1600-6135.2004.0355.x] [Citation(s) in RCA: 217] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The incidence of cardiovascular disease (CVD) is very high in patients with chronic kidney (CKD) disease and in kidney transplant recipients. Indeed, available evidence for these patients suggests that the 10-year cumulative risk of coronary heart disease is at least 20%, or roughly equivalent to the risk seen in patients with previous CVD. Recently, the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (K/DOQI) published guidelines for the diagnosis and treatment of dyslipidemias in patients with CKD, including transplant patients. It was the conclusion of this Work Group that the National Cholesterol Education Program Guidelines are generally applicable to patients with CKD, but that there are significant differences in the approach and treatment of dyslipidemias in patients with CKD compared with the general population. In the present document we present the guidelines generated by this workgroup as they apply to kidney transplant recipients. Evidence from the general population indicates that treatment of dyslipidemias reduces CVD, and evidence in kidney transplant patients suggests that judicious treatment can be safe and effective in improving dyslipidemias. Dyslipidemias are very common in CKD and in transplant patients. However, until recently there have been no adequately powered, randomized, controlled trials examining the effects of dyslipidemia treatment on CVD in patients with CKD. Since completion of the K/DOQI guidelines on dyslipidemia in CKD, the results of the Assessment of Lescol in Renal Transplantation (ALERT) Study have been presented and published. Based on information from randomized trials conducted in the general population and the single study conducted in kidney transplant patients, these guidelines, which are a modified version of the K/DOQI dyslipidemia guidelines, were developed to aid clinicians in the management of dyslipidemias in kidney transplant patients. These guidelines are divided into four sections. The first section (Introduction) provides the rationale for the guidelines, and describes the target population, scope, intended users, and methods. The second section presents guidelines on the assessment of dyslipidemias (guidelines 1-3), while the third section offers guidelines for the treatment of dyslipidemias (guidelines 4-5). The key guideline statements are supported mainly by data from studies in the general population, but there is an urgent need for additional studies in CKD and in transplant patients. Therefore, the last section outlines recommendations for research.
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Johnson BA, Iacono AT, Zeevi A, McCurry KR, Duncan SR. Statin use is associated with improved function and survival of lung allografts. Am J Respir Crit Care Med 2003; 167:1271-8. [PMID: 12615629 DOI: 10.1164/rccm.200205-410oc] [Citation(s) in RCA: 134] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) are widely used antilipidemic agents that are also immunomodulatory. We evaluated possible effects of these agents after lung transplantation by comparing outcomes of 39 allograft recipients, who were prescribed statins for hyperlipidemia, with those of 161 contemporaneous control recipients who did not receive these drugs. Acute rejection (>or= Grade II) was less frequently found in the statin group (15.1 versus 25.6% of biopsies, p < 0.01). None of 15 recipients started on statins during postoperative Year 1 developed obliterative bronchiolitis, whereas the cumulative incidence of this complication among control subjects was 37% (p < 0.01). Total cellularity, as well as proportions of inflammatory neutrophils and lymphocytes, were significantly lower in bronchoalveolar lavages of statin recipients. Among double lung recipients, those taking statins had significantly better spirometry: FVC (80 +/- 2 versus 70 +/- 1%) and FEV1 (87 +/- 2 versus 70 +/- 1%), as percentages of predicted values, and absolute FEV1/FVC (83.4 +/- 1.2 versus 78.6 +/- 0.5) (all p < 0.01). The 6-year survival of recipients taking statins (91%) was much greater than that of control subjects (54%) (p < 0.01). These data suggest statin use may have substantial clinical benefits after pulmonary transplantation.
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Affiliation(s)
- Bruce A Johnson
- Department of Medicine, University of Pittsburgh, 628 NW MUH, 3459 Fifth Ave., Pittsburgh, PA 15213, USA
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REFERENCES. Am J Kidney Dis 2003. [DOI: 10.1016/s0272-6386(03)00125-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Blanco-Colio LM, Tuñón J, Martín-Ventura JL, Egido J. Anti-inflammatory and immunomodulatory effects of statins. Kidney Int 2003; 63:12-23. [PMID: 12472764 DOI: 10.1046/j.1523-1755.2003.00744.x] [Citation(s) in RCA: 241] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Anti-inflammatory and immunomodulatory effects of statins. 3-Hydroxy-3-methyl-gutaryl coenzyme A (HMG-CoA) reductase inhibitors or statins constitute the most powerful class of lipid-lowering drugs. Clinical trials have demonstrated a marked reduction in cardiovascular mortality in patients treated with statins. However, the benefits observed with statin therapy appear to be related, at least in part, with their cholesterol-lowering independent effects. Extensive research carried out mainly in the last decade suggests that the clinical benefits of these drugs could be related to an improvement in endothelial dysfunction, a reduction in blood thrombogenicity, anti-inflammatory properties, and, recently, immunomodulatory actions. In this sense, statins decrease T cell activation, the recruitment of monocytes and T cells into the arterial wall, and enhance the stability of atherosclerotic lesions. Many of these effects are related with the inhibition of isoprenoid synthesis, which serve as a lipid attachment for a variety of proteins implicated in intracellular signaling. In fact, small G proteins, whose proper membrane localization and function are dependent on isoprenylation, may play an important role in the lipid-lowering independent effects of HMG-CoA reductase inhibitors. This article summarizes the anti-inflammatory and immunomodulatory effects of statins and their participation in the different steps of atherosclerotic lesion formation.
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Santos AF, Keitel E, Bittar AE, Neumann J, Fonseca N, Sporleder H, Canabarro R, Kroth L, Saitovitch D, Garcia VD. Simvastatin effect on NK cells activity in vivo: a double-blind randomized, placebo-controlled study. Transplant Proc 2002; 34:2874-5. [PMID: 12431639 DOI: 10.1016/s0041-1345(02)03541-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- A F Santos
- Renal Transplantation Unit, Santa Casa Hospital, Porto Alegre, Brazil
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Palinski W, Tsimikas S. Immunomodulatory effects of statins: mechanisms and potential impact on arteriosclerosis. J Am Soc Nephrol 2002; 13:1673-81. [PMID: 12039998 DOI: 10.1097/01.asn.0000018400.39687.8c] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Clinical trials with statins have demonstrated a marked reduction of cardiovascular mortality. However, it remains controversial whether these clinical benefits stem from powerful cholesterol-lowering effects of statins or whether they are due in part to their cholesterol-independent effects on vascular function, plaque growth, plaque rupture, or thrombosis. The identification of several mechanisms through which statins decrease the recruitment of monocytes and T cells into the arterial wall and inhibit T cell activation and proliferation in vitro have prompted speculations that immunomodulatory effects of statins may be beneficial in recipients of organ transplants. Hypercholesterolemia is frequent in these patients, and delayed-type hypersensitivity reactions in the arterial walls of the graft may be compounded by chronic inflammation associated with conventional atherogenesis. To assess the potential clinical relevance of immunomodulatory effects of statins, the role of the immune system in atherogenesis and the effects of statins in vitro in experimental models and in clinical trials will be reviewed. It is concluded that despite solid in vitro evidence, clinical evidence for an independent immunosuppressive effect of statins in organ transplant patients is presently insufficient; however, further investigation of their in vivo occurrence and clinical relevance is warranted.
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Affiliation(s)
- Wulf Palinski
- Department of Medicine 0682, University of California San Diego, La Jolla, California 92093-0682, USA.
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Abstract
Dyslipidemias are common in patients with chronic kidney disease. The causes vary with the stage of kidney disease, the degree of proteinuria, and the modality of end-stage renal disease treatment. Dyslipidemias have been associated with kidney disease progression, and a number of small, randomized, controlled trials of lipid-lowering agents have been conducted. Unfortunately, the results of these trials, although encouraging, have been inconclusive because of the small numbers of patients enrolled. Dyslipidemias may also contribute to the high incidence of cardiovascular disease in patients with chronic kidney disease. This is most likely for patients with chronic renal insufficiency and for kidney transplant recipients. Less certain is the role of dyslipidemias in the pathogenesis of cardiovascular disease among dialysis patients.
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Affiliation(s)
- Meena Sahadevan
- Department of Medicine, Division of Nephrology, Hennepin County Medical Center, Minneapolis, Minnesota 55414, USA
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Saland JM, Ginsberg H, Fisher EA. Dyslipidemia in pediatric renal disease: epidemiology, pathophysiology, and management. Curr Opin Pediatr 2002; 14:197-204. [PMID: 11981290 DOI: 10.1097/00008480-200204000-00009] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Dyslipidemia increases the risk of cardiovascular events among individuals with renal disease, and there is a growing body of evidence that it hastens the progression of renal disease itself. Children with nephrotic syndrome or renal transplants have easily recognized hyperlipidemia. Among those with chronic renal insufficiency or end-stage renal disease, detection of dyslipidemia requires more careful analysis and knowledge of normal pediatric ranges. Disordered lipoprotein metabolism results from complex interactions among many factors, including the primary disease process, use of medications such as corticosteroids, the presence of malnutrition or obesity, and diet. The systematic treatment of dyslipidemia in children with chronic renal disease is controversial because conclusive data regarding the risks and benefits are lacking. Hepatic 3-methylglutaryl coenzyme A reductase inhibitors (statins), fibrates, plant stanols, bile acid-binding resins, and dietary manipulation are options for individualized treatment. Prospective investigations are required to guide clinical management.
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Affiliation(s)
- Jeffrey M Saland
- Department of Pediatrics, The Mount Sinai Medical Center, New York, New York 10029-6574, USA.
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