Effects of simvastatin on high-sensitivity C-reactive protein and serum albumin in hemodialysis patients

Statin Therapy and Lipid Indices in Chronic Kidney Disease: A Systematic Review and Meta-analysis of Randomized Control Trials

BACKGROUND

Several studies have demonstrated the improvement in serum lipoproteins by statins in patients with Chronic Kidney Diseases (CKDs), including End-Stage Renal Disease (ESRD). However, the results of these studies are inconclusive.

AIM

We aimed to systematically investigate the effect of statins on lipid profiles of patients with CKD by performing a meta-analysis of Randomized Controlled Trials (RCTs).

METHODS

Major electronic databases (Scopus, MEDLINE/PubMed, and ISI Web of Science) were searched from inception to August, 2023, to find randomized controlled trials (RCTs) evaluating the effect of different statins on serum lipoproteins in CKD patients. Weighted Mean Difference (WMD) with 95% Confidence Intervals (CI) was used to estimate the effect size. Trial Sequential Analysis (TSA) was performed to confirm the robustness of the evidence.

RESULTS

A total of 18 publications were identified. It was found that statins reduced serum levels of Low-Density Lipoprotein (LDL)-C (WMD = -27.81 mg/dl, 95% CI = -34.47 to -21.15, P < 0.001) and total cholesterol (WMD = -25.44 mg/dl, 95% CI = -34.71 to -16.18, P < 0.001) in patients with CKD compared to the control group. Nonetheless, the effect of statins on High-Density Lipoprotein (HDL)-C (WMD = 0.57 mg/dl, 95% CI = -0.71 to 1.85, P = 0.38) and Triglyceride (TG) (WMD = -9.08 mg/dl, 95% CI = -22.22 to 2.06, P = 0.11) was not statistically significant. The results of TSA confirmed the robustness of the evidence and were consistent with the pooled effect size. The findings of subgroup analysis and time response analysis were also significant.

CONCLUSION

It was found that statin therapy reduced the levels of LDL-C and total cholesterol in patients with CKD.

Inflammation: the driver of poor outcomes among children with severe acute malnutrition?

Severe acute malnutrition (SAM) is the most life-threatening form of undernutrition and underlies at least 10% of all deaths among children younger than 5 years in low-income countries. SAM is a complex, multisystem disease, with physiological perturbations observed in conjunction with the loss of lean mass, including structural and functional changes in many organ systems. Despite the high mortality burden, predominantly due to infections, the underlying pathogenic pathways remain poorly understood. Intestinal and systemic inflammation is heightened in children with SAM. Chronic inflammation and its consequent immunomodulation may explain the increased morbidity and mortality from infections in children with SAM, both during hospitalization and in the longer term after discharge. Recognition of the role of inflammation in SAM is critical in considering new therapeutic targets in this disease, which has not seen a transformational approach to treatment for several decades. This review highlights the central role of inflammation in the wide-ranging pathophysiology of SAM, as well as identifying potential interventions that have biological plausibility based on evidence from other inflammatory syndromes.

Statins Have an Anti-Inflammation in CKD Patients: A Meta-Analysis of Randomized Trials

Background

Persistent inflammation has been recognized as an important comorbid condition in patients with chronic kidney disease (CKD) and is associated with many complications, mortality, and progression of CKD. Previous studies have not drawn a clear conclusion about the anti-inflammatory effects of statins in CKD. This meta-analysis is aimed at assessing the anti-inflammatory effects of statins therapy in patients with CKD.

Methods

A comprehensive literature search was conducted in these databases (Medline, Embase, Cochrane library, and clinical trials) to identify the randomized controlled trials that assess the anti-inflammatory effects of statins. Subgroup, sensitivity, and trim-and-fill analysis were conducted to determine the robustness of pooled results of the primary outcome.

Results

25 eligible studies with 7921 participants were included in this meta-analysis. The present study showed that statins therapy was associated with a decreased C-reactive protein (CRP) (-2.06 mg/L; 95% CI: -2.85 to -1.27, p < 0.01). Subgroup, sensitivity, and trim-and-fill analysis showed that the pooled results of CPR were stable.

Conclusion

This meta-analysis demonstrates that statins supplementation has anti-inflammatory effects in patients with CKD. Statins exert an anti-inflammatory effect that is clinically important in improving complications, reducing mortality, and slowing progression in CKD. We believe that the benefits of statins to CKD are partly due to their anti-inflammatory effects. However, stains usually are prescribed in the CKD patients with dyslipidemia, whether statins can reduce inflammation in CKD patients with normal serum lipid needed to explore in the future. Therefore, we suggest that randomized clinical trials need to assess the effect of statins in CKD patients with normal serum lipid. Whether statins can be prescribed for aiming to inhibit inflammation in CKD also needed further study. Trial Registration. The study protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO); registration number: CRD42022310334.

Statins Decrease the Risk of Orbitopathy in Newly Diagnosed Patients with Graves Disease

CONTEXT/OBJECTIVE

The aim of this study was to examine the effect of statins and other lipid-lowering agents on the development of Graves orbitopathy (GO) in patients with newly diagnosed Graves disease (GD).

METHODS

Our sample included the full adult population of individuals living in Sweden with newly diagnosed GD between 2005 and 2018 (n = 34 894). We compared the GO incidence in statin users (n = 5574) and nonusers (n = 34 409) by applying Cox regression with a time-varying exposure variable. We adjusted for age, sex, and treatment for hyperthyroidism in the multivariate analyses.

RESULTS

Periods of nonusage lasted for a median of 4.3 years (interquartile range [IQR] 1.2-8.4), whereas periods of usage lasted for a median of 4.7 years (IQR 2.0-8.1). Among statin users, 77.1% had used simvastatin, 28.9% atorvastatin, and 8.2% had used other statins. Statin users were found to be significantly less likely to develop GO. In the main analysis based on the full cohort, the unadjusted hazard ratio (HR) was 0.74 (CI 0.65-0.84, P < .001), whereas full adjustment altered the effect to 0.87 (CI 0.76-1.00, P = .04). The main results were largely driven by men; the fully adjusted HR was 0.78 (CI 0.58-1.04, P = .09) for men and 0.91 (CI 0.79-1.06, P = .24) for women. Lipid-lowering agents other than statins did not exhibit a similar protective effect.

CONCLUSION

In newly diagnosed patients with GD, treatment with statins may protect against the development of GO. Statins should be investigated in a clinical trial as a preventive treatment for GO in newly diagnosed patients with GD.

Immune Dysfunction in Dialysis Patients—Prevention and Treatment Strategies

Immune dysfunction, resulting in infection or inflammation, or both, is closely associated with poor clinical outcome in end-stage renal disease patients. So far, no single measure can effectively address this condition, because many factors, such as uremia per se and dialysis treatment are involved in the pathogenesis. Our review focuses on currently available treatments and prevention options, and identifies future research needs.

Effect of atorvastatin on inflammatory markers in hemodialysis patients

Background

Cardiovascular disease is the commonest cause of death in patients with end-stage renal disease (ESRD) under maintenance hemodialysis. Dyslipidemia, oxidative stress, and low-grade inflammation with increased circulating cytokines are factors that increase the cardiovascular risk in patients with chronic kidney disease, in addition to traditional risk factors, such as obesity, hypertension, and diabetes. We aimed to investigate the possible anti-inflammatory effects of atorvastatin in prevalent hemodialysis patients. Fifty-three stable adult hemodialysis patients were assigned into two groups (a drug group and a control group). Patients in the drug group received 20 mg of atorvastatin daily for 6 months. Serum levels of highly sensitive C-reactive protein (hs-CRP) and interleukin-6 (IL-6) were measured in both groups at baseline and at the end of the study period.

Results

Atorvastatin therapy caused a statistically significant decrease in levels of hs-CRP but no change in levels of IL-6 after 6 months of therapy.

Conclusions

In addition to its favorable effect on lipid profile parameters, atorvastatin therapy can be considered as an effective and safe modality to overcome the problem of chronic inflammation encountered in end-stage renal disease patients.

Acute Systemic Inflammation is Associated with an Increase in Peritoneal Solute Transport Rate in Chronic Peritoneal Dialysis Patients

Background

This study was performed to evaluate the effects of acute systemic inflammation on peritoneal solute transport rate (PSTR) in chronic peritoneal dialysis (CPD) patients.

Methods

A baseline standard peritoneal equilibration test (PET) was performed on each patient every 6 months, and blood concentration of high-sensitivity C-reactive protein (hs-CRP) was assayed every 2 months in our peritoneal dialysis clinic. Acute systemic inflammation was defined as a greater than 10-fold increase in hs-CRP concentration compared with baseline value, in the absence of peritonitis, and returning to baseline level in 2 months. In patients with acute systemic inflammation, PET and hs-CRP concentration assays were performed during inflammation and after recovery. Ten patients with acute systemic inflammation were enrolled in the inflammation group and 42 other patients served as controls.

Results

There were no significant changes in hs-CRP and dialysate-to-plasma ratio of creatinine (D/Pcreat) in the control group during the study period. In the inflammation group, median hs-CRP levels at baseline, during acute inflammation, and at recovery were 2.3 mg/L (range 0.3 – 4.5 mg/L), 39.2 mg/L (range 15.1 – 117.4 mg/L), and 3.7 mg/L (range 0.9 – 8.9 mg/L), respectively. Median D/Pcreat increased significantly from baseline (0.64; range 0.55 – 0.98) to time of acute inflammation (0.72; range 0.60 – 0.96) ( p < 0.05). The D/Pcreat at recovery was 0.67 (range 0.52 – 0.94), which decreased significantly from time of acute inflammation ( p < 0.05). There was no correlation between changes in log (hs-CRP) and changes in D/Pcreat.

Conclusion

We have shown here that acute systemic inflammation is associated with a temporary increase in PSTR in CPD patients.

Statins for Treatment of Dyslipidemia in Chronic Kidney Disease

Dyslipidemia is a potent cardiovascular (CV) risk factor in the general population. Elevated low-density lipoprotein cholesterol (LDL-C) and/or low high-density lipoprotein (HDL-C) are well-established CV risk factors, but more precise determinants of risk include increased apoprotein B (ApoB), lipoprotein(a) [Lp(a)], intermediate and very low-density lipoprotein (IDL-C, VLDL-C; “remnant particles”), and small dense LDL particles. Lipoprotein metabolism is altered in association with declining glomerular filtration rate such that patients with non dialysis-dependent chronic kidney disease (CKD) have lower levels of HDL-C, higher triglyceride, ApoB, remnant IDL-C, remnant VLDL-C, and Lp(a), and a greater proportion of oxidized LDL-C. Similar abnormalities are prevalent in hemodialysis (HD) patients, who often manifest proatherogenic changes in LDL-C in the absence of increased levels. Patients treated with peritoneal dialysis (PD) have a similar but more severe dyslipidemia compared to HD patients due to stimulation of hepatic lipoprotein synthesis by glucose absorption from dialysate, increased insulin levels, and selective protein loss in the dialysate analogous to the nephrotic syndrome. In the dialysis-dependent CKD population, total cholesterol is directly associated with increased mortality after controlling for the presence of malnutrition–inflammation.

Treatment with statins reduces CV mortality in the general population by approximately one third, irrespective of baseline LDL-C or prior CV events. Statins have similar, if not greater, efficacy in altering the lipid profile in patients with dialysis-dependent CKD (HD and PD) compared to those with normal renal function, and are well tolerated in CKD patients at moderate doses (≤ 20 mg/day atorvastatin or simvastatin). Statins reduce C-reactive protein as well as lipid moieties such as ApoB, remnants IDL and VLDL-C, and oxidized and small dense LDL-C fraction. Large observational studies demonstrate that statin treatment is independently associated with a 30% – 50% mortality reduction in patients with dialysis-dependent CKD (similar between HD- and PD-treated patients). One recent randomized controlled trial evaluated the ability of statin treatment to reduce mortality in type II diabetics treated with HD (“4D”); the primary end point of death from cardiac cause, myocardial infarction, and stroke was not significantly reduced. However, results of this trial may not apply to other end-stage renal disease populations. Two ongoing randomized controlled trials (SHARP and AURORA) are underway evaluating the effect of statins on CV events and death in patients with CKD (including patients treated with HD and PD). Recruitment to future trials should be given a high priority by nephrologists and, until more data are available, consideration should be given to following published guidelines for the treatment of dyslipidemia in CKD. Additional consideration could be given to treating all dialysis patients felt to be at risk of CV disease (irrespective of cholesterol level), given the safety and potential efficacy of statins. This is especially relevant in patients treated with PD, given their more atherogenic lipid profile and the lack of randomized controlled trials in this population.

Anti-Inflammatory Effects of 3-Hydroxy-3-Methylglutaryl Coenzyme a Reductase Inhibitors (Statins) in Peritoneal Dialysis Patients

Objective

Elevated C-reactive protein (CRP) level is an independent predictor of all-cause and cardiovascular mortality in peritoneal dialysis (PD) patients. Statins have been demonstrated to have anti-inflammatory properties by virtue of their CRP lowering effects in hemodialysis patients. However, whether statins have an anti-inflammatory effect in PD patients is unknown.

Design

All prevalent PD patients at our center were reviewed. Eligible (257) patients were categorized into 2 groups: those on statin therapy ( n = 137) and those not on statins ( n = 120). Data were abstracted for hemoglobin, albumin, phosphates, cholesterol, CRP, Kt/V, and erythropoietin dose, along with relevant clinical data.

Results

The two groups had similar concentrations of hemoglobin, albumin, and phosphates. They were also matched for dialysis adequacy and duration of dialysis but the statin group patients were older (57 ± 13 vs 52 ± 17 years, p = 0.01). Serum cholesterol was lower in the statin group (4.74 ± 1.05 vs 5.02 ± 1.17 mmol/L, p < 0.05). Single-point (14 ± 13 vs 19 ± 18 mg/L, p < 0.02) and serially measured CRP (9 ± 7.4 vs 12 ± 10 mg/L, p < 0.02) levels were significantly lower in the statin group despite increased comorbidity (0.84 vs 0.54, p < 0.02) and greater incidence of diabetes mellitus (52% vs 25%, p < 0.01).

Conclusion

Statin therapy is associated with low single-point and serially measured CRP levels in PD patients, thereby suggesting that their anti-inflammatory properties persist in PD. These data have implications for considering statin therapy in PD patients as an anti-inflammatory agent in addition to a cholesterol lowering drug.

Effects of Sulodexide on Hemostatic Factors, Lipid Profile, and Inflammation in Chronic Peritoneal Dialysis Patients

Sulodexide, a standardized extractive glycosaminoglycan containing 80% “fast moving” heparin and 20% dermatan sulfate, decreased plasma D-dimer, a marker of intravascular coagulation, and fibrinogen levels in chronic peritoneal dialysis patients. Blood levels of von Willebrand factor, lipid, and high-sensitivity C-reactive protein were not significantly changed. No bleeding episodes were reported. These results suggest that sulodexide was effective in partially reversing the thrombogenic coagulation profile without increasing the risk of bleeding.

A revised systematic review and meta-analysis on the effect of statins on D-dimer levels

BACKGROUND

D-dimers are generated during endogenous fibrinolysis of a blood clot and have a central role in diagnostic algorithms to rule out venous thromboembolism. HMG-CoA reductase inhibitors, more commonly called statins, are known to have effects independent of LDL-cholesterol lowering, including antithrombotic properties. An effect of statins on D-dimer levels has been reported in a prior systematic review and meta-analysis, but methodological shortcomings might have led to an overestimated effect. To re-evaluate the association between statins and D-dimer levels, we systematically reviewed all published articles on the influence of statins on D-dimer levels and conducted a novel meta-analysis (PROSPERO registration number CRD42017058932).

MATERIALS AND METHODS

We electronically searched EMBASE, Medline Epub, Cochrane, Web of Science and Google Scholar (100 top relevance) (date of last search: 5 October 2017). We included randomized controlled trials, cohort studies and cross-sectional studies. Two reviewers independently screened all articles retrieved and extracted data on study and patient characteristics, study quality and D-dimer levels.

RESULTS

Study-level meta-analysis involving 18,052 study participants showed lower D-dimer levels in those receiving statin treatment than controls (SMD: -0.165, 95% CI -0.234; -0.096, P = <0.001). Sensitivity analyses and additional analyses on treatment duration (<12 weeks vs ≥12 weeks) and type of statin (lipophilic or hydrophilic) did not modify this overall result.

CONCLUSION

This meta-analysis suggests an association between use of statins and reduction of D-dimer levels, independent of treatment duration and type of statin used. This effect is small but robust, and should be interpreted with caution.

Effect of statin treatment on circulating malondialdehyde concentrations: a systematic review and meta-analysis

Background

The effect of statins on oxidative stress markers, such as malondialdehyde (MDA), is still a matter of debate. We sought to address this issue by conducting a systematic review and meta-analysis of published data on the effect of statin treatment on systemic MDA concentrations.

Methods

A literature search was conducted on MEDLINE/PubMed, ISI Web of Sciences and Scopus. Data were pooled using a random-effects model.

Results

A total of 35 studies assessing MDA concentrations before and after statin treatment in 1512 participants (mean age 53.6 years, 48.7% males) were identified. Extreme between-study heterogeneity was observed (I² = 96.0%, p < 0.001). Pooled standardized mean difference (SMD) showed a significant reduction in plasma MDA concentrations after treatment (SMD = -1.47 µmol/l, 95% confidence interval = -1.89 to -1.05 μmol/l; p < 0.001). Similarly, a subgroup analysis of 10 studies that also included a placebo group showed a significant reduction in plasma MDA concentrations with statins (-1.03 μmol/l, 95% confidence interval = -1.52 to -0.29 μmol/l; p = 0.036).

Conclusions

This systematic review and meta-analysis showed that statin treatment significantly reduces systemic MDA concentrations. However, the results should be interpreted with caution because of extreme between-study heterogeneity, which warrants further intervention studies.

Cholesterol Serum Levels and Use of Statins in Graves' Orbitopathy: A New Starting Point for the Therapy

Graves' Orbitopathy (GO) is the most frequent extrathyroidal manifestation of Graves' disease (GD). Its ultimate cause remains unclear, but it is commonly considered an autoimmune disorder due to self recognition of autoantigens constitutively expressed by orbital fibroblasts (OFs), and thyroid epithelial cells. High dose intravenous glucocorticoids (ivGC) are the most commonly used treatment for moderately severe and active GO. However, based on the complex pathogenesis of GO, a number of factors may have a protective and maybe a therapeutic role. The use of other medications improving the effect of GC may increase the overall effectiveness of the therapy and reduce GC doses, thereby limiting side effects. Recently, a possible protective role of 3-hydroxy-3-methylglutaryl-coenzyme reductase inhibitors, the so-called statins, and perhaps of lowering cholesterol levels, has been proposed. Thus, statins have been reported to be associated with a reduced frequency of GO in GD patients and in recent cross-sectional and retrospective studies a significant correlation was found between the occurrence of GO and both total and LDL-cholesterol in patients with a GD of relatively recent onset, suggesting a role of cholesterol in the development of GO. Moreover, a correlation was found between the GO clinical activity score and total as well as LDL-cholesterol in untreated GO patients, depending on GO duration, indicating a role of cholesterol on GO activity. Therefore, statin treatment may be beneficial for GO. Here we review this subject, which offers new therapeutic perspectives for patients with GO.

Anti-Inflammatory Effect of Atorvastatin on the Kidney Graft of Living Donor Transplants

Background

Recent studies have demonstrated that statins have anti-inflammatory and immunomodulatory properties, which could be considered beneficial in kidney transplantations. This study assesses the anti-inflammatory effect of atorvastatin on the kidney grafts of living donor transplants.

Material/Methods

In a randomized clinical trial, kidney donors were divided into 2 groups. The study group constituted 24 donors who received 40 mg atorvastatin, and 24 donors who received a placebo control, 4 weeks prior to transplantation. Serum C-reactive protein (CRP) levels were measured before and after atorvastatin administration. CRP and renal function of kidney recipients were measured at baseline and 1, 6, and 24 hours after transplantation.

Results

After 4 weeks of treatment, the CRP level was 5.62±3.82 mg/dL in the control group and 3.27±0.62 mg/dL in the study group (P=0.007). Upon reperfusion, CRP levels in recipients at 1 hour were, 5.8±3.9 and 3.8±1.0 mg/dL, respectively (P=0.04). Twenty-four hours after the kidney transplantations, serum creatinine levels were 2.5±1.5 mg/dL in the study group and 3.7±2.4 mg/dL in the control group (P=0.04).

Conclusions

Our study suggests that the use of atorvastatin prior to allograft procurement of kidney transplant, reduces the acute kidney inflammatory burden profile, and promotes an improved kidney function recovery following transplantation.

Association between statin use and plasma D-dimer levels

D-dimers, specific breakdown fragments of cross-linked fibrin, are generally used as circulating markers of activated coagulation. Statins influence haemostatic factors, but their effect on plasma D-dimer levels is controversial. Therefore, the aim of this meta-analysis was to evaluate the association between statin therapy and plasma D-dimer levels. We searched PubMed, Web of Science, Cochrane Library, Scopus and EMBASE (up to September 25, 2014) to identify randomised controlled trials (RCTs) investigating the impact of statin therapy on plasma D-dimer levels. Two independent reviewers extracted data on study characteristics, methods and outcomes. Meta-analysis of data from nine RCTs with 1,165 participants showed a significant effect of statin therapy in reducing plasma D-dimer levels (standardised mean difference [SMD]: –0.988 µg/ml, 95 % confidence interval [CI]: –1.590 – –0.385, p=0.001). The effect size was robust in sensitivity analysis and omission of no single study significantly changed the overall estimated effect size. In the subgroup analysis, the effect of statins on plasma D-dimer levels was significant only in the subsets of studies with treatment duration ≥ 12 weeks (SMD: –0.761 µg/ml, 95 %CI: –1.163– –0.360; p< 0.001), and for lipophilic statins (atorvastatin and simvastatin) (SMD: –1.364 µg/ml, 95 % CI: –2.202– –0.526; p=0.001). Hydrophilic statins (pravastatin and rosuvastatin) did not significantly reduce plasma D-dimer levels (SMD: –0.237 µg/ml, 95 %CI: –1.140–0.665, p=0.606). This meta-analysis of RCTs suggests a decrease of plasma D-dimer levels after three months of statin therapy, and especially after treatment with lipophilic statins. Well-designed trials are required to validate these results.

Note: The review process for this paper was fully handled by Christian Weber, Editor in Chief.

Benefit of Ezetimibe Added to Simvastatin in Reduced Kidney Function

Efficacy of statin-based therapies in reducing cardiovascular mortality in individuals with CKD seems to diminish as eGFR declines. The strongest evidence supporting the cardiovascular benefit of statins in individuals with CKD was shown with ezetimibe plus simvastatin versus placebo. However, whether combination therapy or statin alone resulted in cardiovascular benefit is uncertain. Therefore, we estimated GFR in 18,015 individuals from the IMPROVE-IT (ezetimibe plus simvastatin versus simvastatin alone in individuals with cardiovascular disease and creatinine clearance >30 ml/min) and examined post hoc the relationship of eGFR with end points across treatment arms. For the primary end point of cardiovascular death, major coronary event, or nonfatal stroke, the relative risk reduction of combination therapy compared with monotherapy differed by eGFR (P=0.04). The difference in treatment effect was observed at eGFR≤75 ml/min per 1.73 m2 and most apparent at levels ≤60 ml/min per 1.73 m2 Compared with individuals receiving monotherapy, individuals receiving combination therapy with a baseline eGFR of 60 ml/min per 1.73 m2 experienced a 12% risk reduction (hazard ratio [HR], 0.88; 95% confidence interval [95% CI], 0.82 to 0.95); those with a baseline eGFR of 45 ml/min per 1.73 m2 had a 13% risk reduction (HR, 0.87; 95% CI, 0.78 to 0.98). In stabilized individuals within 10 days of acute coronary syndrome, combination therapy seemed to be more effective than monotherapy in individuals with moderately reduced eGFR (30-60 ml/min per 1.73 m2). Further studies examining potential benefits of combination lipid-lowering therapy in individuals with CKD are needed.

Randomized comparative efficacy and safety study of intermittent simvastatin versus fenofibrate in hemodialysis

AIM

Compare the safety and efficacy of intermittent fenofibrate versus simvastatin in chronic hemodialysis patients.

PATIENTS & METHODS

Sixty patients received either fenofibrate 100 mg or simvastatin 20 mg after their dialysis session (parallel study). The safety and efficacy of drugs on lipid profile, oxidized low-density lipoprotein (Ox-LDL), glutathione peroxidase and C-reactive protein were compared before and after 16-week treatment.

RESULTS

After treatment, significant increase in glutathione peroxidase, significant decrease in total cholesterol, triglycerides, low density lipoprotein (LDL) and ox-LDL (p < 0.05) and no significant changes in C-reactive protein (p > 0.05) were observed in both groups. Both drugs were well tolerated with no serious side effects reported by the patients.

CONCLUSION

Both drugs have comparable efficacy and safety when used as intermittent low dose regimen in hemodialysis. Larger studies with longer follow-up periods are needed to confirm our new findings.

Erythropoietin Hyporesponsiveness in Dialysis Patients: Possible Role of Statins

BACKGROUND

Hypothesizing that statins may be useful as adjuvant treatment for renal anemia, we examined the association between statin prescription (Rx) and erythropoiesis-stimulating agent (ESA) hyporesponsiveness in Japanese hemodialysis (HD) patients prescribed ESAs.

METHODS

We examined 3,602 patients in 60 HD facilities dialyzed 3 times/week for ≥4 months from the Japan Dialysis Outcomes and Practice Patterns Study phases 3-5 (2005-2015). Statin Rx was reported at the end of a 4-month interval (baseline) for each patient. ESA hyporesponsiveness in the subsequent 4 months was then defined as a binary indicator (mean hemoglobin [Hgb] level <10 g/dL and mean ESA dose >6,000 units/week) and separately as the ESA resistance index (ERI; mean ESA dose/[dry weight × mean Hgb]). We used adjusted logistic and linear regressions to evaluate the associations between statin Rx and ESA hyporesponsiveness.

RESULTS

At baseline, 16.2% of patients reported statin Rx; 12.8% were classified as having ESA hyporesponsiveness during 4 months of follow-up. Compared to patients without statin Rx, patients with statin Rx had lower odds of ESA hyporesponsiveness (OR 0.87; 95% CI 0.66-1.15). Similarly, the ERI was lower for those with statin Rx than without (ratio of means, 0.94; 95% CI 0.89-0.99) after adjustment for possible confounders.

CONCLUSIONS

Our results suggest that statins may slightly reduce ESA hyporesponsiveness in HD patients. However, any causal inference is limited by the observational study design and unmeasured compliance with statin Rx.

Oxidative Stress Biomarkers and Left Ventricular Hypertrophy in Children with Chronic Kidney Disease

Cardiovascular diseases remain the most frequent cause of morbidity and mortality in patients with chronic kidney disease (CKD). The aim of the study was to assess the association between oxidative stress biomarkers and cardiovascular risk factors and left ventricular hypertrophy in children with CKD. Material and Methods. The studied group consisted of 65 patients aged 1.4-18.6 (mean 11.2) years with stages 1 to 5 CKD. Serum oxidized low-density lipoprotein (oxLDL), protein carbonyl group, creatinine, cystatin C, albumin, lipids, high-sensitivity C-reactive protein, intercellular adhesion molecule-1, insulin, plasma renin activity, and aldosterone levels were measured. Patients were divided into groups depending on CKD stage. Anthropometric measurements, ambulatory blood pressure (BP) measurements, and echocardiography with left ventricular mass (LVM) calculation were performed. Results. Serum oxLDL strongly correlated with creatinine (R = 0.246; p = 0.048), cystatin C (R = 0.346; p = 0.006), total cholesterol (R = 0.500; p < 0.001), triglycerides (R = 0.524; p < 0.001), low-density lipoprotein concentrations (R = 0.456; p < 0.001), and 24 hour BP values of systolic (R = 0.492; p = 0.002), diastolic (R = 0.515; p < 0.001), and mean arterial pressure (R = 0.537; p < 0.001). A significant correlation between oxLDL levels and LVM z-scores (R = 0.299; p = 0.016) was found. Conclusions. Hypertension and dyslipidemia correlated with lipid oxidation in children with CKD. oxLDLs seem to be valuable markers of oxidative stress in CKD patients, correlating with left ventricular hypertrophy.

Risk factors for developing thyroid-associated ophthalmopathy among individuals with Graves disease

IMPORTANCE

Thyroid-associated ophthalmopathy (TAO) is a common and debilitating manifestation of Graves disease (GD). Presently little is known about factors that may increase the risk of developing TAO among patients with GD.

OBJECTIVE

To identify risk factors associated with the development of TAO among individuals with newly diagnosed GD.

DESIGN, SETTING, AND PARTICIPANTS

In this longitudinal cohort study, all beneficiaries 18 years of age or older with newly diagnosed GD who were continuously enrolled in a large nationwide US managed care network and who visited an eye care professional 1 or more times from 2001 to 2009 were identified. International Classification of Diseases, Ninth Revision, Clinical Modification billing codes were used to identify those who developed manifestations of TAO. Multivariable Cox regression was used to determine the hazard of developing TAO among persons with newly diagnosed GD, with adjustment for sociodemographic factors, systemic medical conditions, thyrotropin levels, and medical and surgical interventions for management of hyperthyroidism.

MAIN OUTCOMES AND MEASURES

Manifestations of TAO measured by hazard ratios (HRs) with 95% CIs.

RESULTS

Of 8404 patients with GD who met the inclusion criteria, 740 (8.8%) developed TAO (mean follow-up, 374 days since initial GD diagnosis). After adjustment for potential confounders, surgical thyroidectomy, alone or in combination with medical therapy, was associated with a 74% decreased hazard for TAO (adjusted HR, 0.26 [95% CI, 0.12-0.51]) compared with radioactive iodine therapy alone. Statin use (for ≥60 days in the past year vs <60 days or nonuse) was associated with a 40% decreased hazard (adjusted HR, 0.60 [CI, 0.37-0.93]). No significant association was found for the use of nonstatin cholesterol-lowering medications or cyclooxygenase 2 inhibitors and the development of TAO.

CONCLUSIONS AND RELEVANCE

If prospective studies can confirm our finding that a thyroidectomy and statin use are associated with substantially reduced hazards for TAO among patients with GD, preventive measures for this burdensome manifestation of GD may become a reality.

Anti-inflammatory effect of simvastatin in hemodialysis patients

Background

Patients in the final stages of renal failure have accelerated inflammation conditions. Inflammation causes progressive kidney damage, faster progression of atherogenesis, chronic malnutrition and increased anemia, resulting in lower life expectancy of patients under dialysis. Statins have pleiotropic effects, because the drug has effects more than just decreasing lipids such as antioxidant effects, changes in endothelial dysfunction, stabilizing the plaque and immune system regulator.

Objectives

The aim of the study was to evaluate anti-inflammatory effect of simvastatin (one of the statins) in patients under hemodialysis.

Patients and Methods

In this clinical trial study, 40 patients under hemodialysis were studied for 12 weeks. Patients were divided into treatment (25 cases) and control groups (15 cases). The treatment group received a daily dosage of 20 mg of simvastatin, while the control group received no medication. The serum amounts of hs-CRP, IL6, Hb and WBC count were measured and compared at baseline and after 12 weeks. In addition, probable hepatic and muscular complications were studied in patients.

Results

At baseline, each of treatment and control groups had similar characteristics. During the study, the average level of CRP decreased in the treatment group (P = 0.04), while it was increased in the control group. The amount of serum IL-6 dropped in the treatment group (P = 0.01); however, it was increased in the control group. In both groups, the level of Hb increased significantly at the end of study in the treatment group (P = 0.007) and the control group (P = 0.016). The average WBC count decreased significantly in the treatment group and the control group (P = 0.003). There was no significant change in hepatic and muscular enzymes in the two groups.

Conclusions

End stage renal disease (ESRD) have accelerated inflammatory conditions. Simvastatin clearly lowers the serum levels of CRP and IL-6, and the white blood cell count in dialysis patients. Administering Simvastatin to dialysis patients is safe.

Obesity and kidney protection

CONTEXT

Obesity, both directly and indirectly, increases the risk for a variety of disease conditions including diabetes, hypertension, liver disease, and certain cancers, which in turn, decreases the overall lifespan in both men and women. Though the cardiovascular risks of obesity are widely acknowledged, less often identified is the relationship between obesity and renal function.

EVIDENCE ACQUISITIONS

Directory of Open Access Journals (DOAJ), Google Scholar, PubMed, EBSCO and Web of Science has been searched.

RESULTS

The concept of the "Metabolic Syndrome" helps us to understand this close link between obesity, diabetes, hypertension, and renal dysfunction. An elevated body mass index has shown to be one of the major determinants of glomerular hyperfiltration that lead to the development of chronic kidney disease. Interestingly, weight loss can lead to attenuation of hyperfiltration in severely obese patients suggesting a possible therapeutic option to combat obesity-related hyperfiltration.

CONCLUSIONS

Various treatment strategies had been suggested to decrease impact of obesity on kidneys. These are blood pressure controling, inhibition of the renin-angiotensinaldosterone axis, improving glycemic control, improving dyslipidemia, improving protein uriaand lifestyle modifications. Regardless of the numerous pharmacotherapies, the focus should be on the root cause: obesity.

Dyslipidemia and progression of kidney disease: role of lipid-lowering drugs

HMG-CoA reductase inhibitors (statins) have been shown to reduce cardiovascular morbidity in patients with normal and abnormal kidney function but not in patients with end-stage kidney disease. Evidence supports a role for statins in delaying the progression of kidney disease in a variety of experimental models in animals. However, the evidence that statins may retard CKD progression in humans is scant. In this review, we critically consider the available data supporting a role for statins in CKD progression in humans and the possibility that there might be differences among statins in regards to effects on the kidneys. Finally, we review the evidence that statins may increase the risk of acute kidney injury.

HMG CoA reductase inhibitors (statins) for dialysis patients

BACKGROUND

People with advanced kidney disease treated with dialysis experience mortality rates from cardiovascular disease that are substantially higher than for the general population. Studies that have assessed the benefits of statins (HMG CoA reductase inhibitors) report conflicting conclusions for people on dialysis and existing meta-analyses have not had sufficient power to determine whether the effects of statins vary with severity of kidney disease. Recently, additional data for the effects of statins in dialysis patients have become available. This is an update of a review first published in 2004 and last updated in 2009.

OBJECTIVES

To assess the benefits and harms of statin use in adults who require dialysis (haemodialysis or peritoneal dialysis).

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

Randomised controlled trials (RCTs) and quasi-RCTs that compared the effects of statins with placebo, no treatment, standard care or other statins on mortality, cardiovascular events and treatment-related toxicity in adults treated with dialysis were sought for inclusion.

DATA COLLECTION AND ANALYSIS

Two or more authors independently extracted data and assessed study risk of bias. Treatment effects were summarised using a random-effects model and subgroup analyses were conducted to explore sources of heterogeneity. Treatment effects were expressed as mean difference (MD) for continuous outcomes and risk ratios (RR) for dichotomous outcomes together with 95% confidence intervals (CI).

MAIN RESULTS

The risk of bias was high in many of the included studies. Random sequence generation and allocation concealment was reported in three (12%) and four studies (16%), respectively. Participants and personnel were blinded in 13 studies (52%), and outcome assessors were blinded in five studies (20%). Complete outcome reporting occurred in nine studies (36%). Adverse events were only reported in nine studies (36%); 11 studies (44%) reported industry funding.We included 25 studies (8289 participants) in this latest update; 23 studies (24 comparisons, 8166 participants) compared statins with placebo or no treatment, and two studies (123 participants) compared statins directly with one or more other statins. Statins had little or no effect on major cardiovascular events (4 studies, 7084 participants: RR 0.95, 95% CI 0.88 to 1.03), all-cause mortality (13 studies, 4705 participants: RR 0.96, 95% CI 0.90 to 1.02), cardiovascular mortality (13 studies, 4627 participants: RR 0.94, 95% CI 0.84 to 1.06) and myocardial infarction (3 studies, 4047 participants: RR 0.87, 95% CI 0.71 to 1.07); and uncertain effects on stroke (2 studies, 4018 participants: RR 1.29, 95% CI 0.96 to 1.72).Risks of adverse events from statin therapy were uncertain; these included effects on elevated creatine kinase (5 studies, 3067 participants: RR 1.25, 95% CI 0.55 to 2.83) or liver function enzymes (4 studies, 3044 participants; RR 1.09, 95% CI 0.41 to 1.25), withdrawal due to adverse events (9 studies, 1832 participants: RR 1.04, 95% CI 0.87 to 1.25) or cancer (2 studies, 4012 participants: RR 0.90, 95% CI 0.72 to 1.11). Statins reduced total serum cholesterol (14 studies, 1803 participants; MD -44.86 mg/dL, 95% CI -55.19 to -34.53) and low-density lipoprotein cholesterol (12 studies, 1747 participants: MD -39.99 mg/dL, 95% CI -52.46 to -27.52) levels. Data comparing statin therapy directly with another statin were sparse.

AUTHORS' CONCLUSIONS

Statins have little or no beneficial effects on mortality or cardiovascular events and uncertain adverse effects in adults treated with dialysis despite clinically relevant reductions in serum cholesterol levels.

A meta-analysis of the role of statins on renal outcomes in patients with chronic kidney disease. Is the duration of therapy important?

INTRODUCTION

The efficacy of statin treatment in chronic kidney disease (CKD) patients remains controversial. Therefore, we performed a meta-analysis to investigate whether statins modulate renal function in patients with CKD.

METHODS

Data from Scopus, PubMed, Web of Science, and the Cochrane Central Register of randomized controlled trials for years 1966-December 2012 were searched for appropriate studies.

RESULTS

Twenty trials with 6452 CKD subjects randomized to receive either statin or placebo were included. Statin therapy significantly influenced high sensitivity C-reactive protein levels in patients on or off dialysis [-0.28 mg/dl, 95%CI: -0.93 to -0.37; p<0.05 and -0.46 mg/dl, 95%CI: -0.87 to -0.05; p=0.03], respectively], urinary protein (-0.77 g/24 h, 95%CI: -1.24 to -0.29, p<0.02; this effect persisted for treatment ≤12 months), and serum creatinine but only for long-term therapy (3 years) (-0.65 mg/dl, 95%CI: -1.00 to -0.30; p=0.0003). The summary for standardized effect size of mean differences of glomerular filtration rate was 0.29 ml/min/1.73 m(2) (95%CI: 0.01 to 0.58; p=0.04), and depended on treatment duration - a significant increase was observed for between 1 and 3 years of statin therapy (0.50 ml/min/1.73 m(2), 95%CI: 0.40 to 0.60; p<0.0001), with no significant increase for both ≤1 and >3 years of the therapy.

CONCLUSION

Statins might exert significant renoprotective effects in CKD patients; however, benefit may depend on the duration of treatment. This is an issue that warrants more definitive investigation. More studies are necessary in dialysis patients to credibly evaluate the renal effects of statin therapy.

Effects of statins on lipid profile in chronic kidney disease patients: a meta-analysis of randomized controlled trials

OBJECTIVE

The available data on statin effects in chronic kidney disease (CKD) patients are still conflicting. We investigated the impact of short- and long-term statin therapy on lipid profiles in CKD patients requiring or not requiring dialysis.

RESEARCH DESIGN AND METHODS

Data from Scopus, PubMed, Web of Science, and the Cochrane Library from 1966 to May 2012 were searched for studies that investigated this effect. We included all randomized controlled clinical trials that investigated the impact of statin therapy on lipids and lipoproteins.

RESULTS

The final analysis included 16 trials with 3594 subjects. In CKD patients, statin therapy significantly reduced total cholesterol (TC), triglycerides (TG) and low-density lipoprotein cholesterol (LDL-C) (p < 0.003 for all comparisons), and the effect insignificantly intensified with duration of statin therapy (56.3 vs 66.8, 22.5 vs 24.1, and 53 vs 56.1 mg/dl, respectively). Comparing statin therapy for ≤ 3 and >3 months in CKD patients on dialysis, the magnitude of TC and LDL-C decreased (26.3 vs 25.9, and 42.2 vs 29.8 mg/dl, respectively, p > 0.05 for both), while TG increased modestly (4.5 vs 13.4 mg/dl). Short-term statin therapy increased high density lipoprotein cholesterol by a mean 0.7 mg/dl (p = 0.04), and long-term therapy was associated with a mean reduction of 2.4 mg/dL.

CONCLUSIONS

Statin therapy significantly modifies the lipid profile in CKD patients not on dialysis therapy (with the trend to be more effective with longer therapy), and have less beneficial effect in patients on dialysis with the trend to be less effective with longer duration of therapy.

Effect of statins on chronic inflammation and nutrition status in renal dialysis patients: a systematic review and meta-analysis

AIM

3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) may have an adjunctive effect on chronic inflammation and nutrition status in renal dialysis patients. Therefore, we performed a systematic review of randomized controlled trials to assess the effect of statins on chronic inflammation and nutrition status in dialysis patients.

METHODS

The randomized controlled trials (RCTs) of statins versus placebo or no treatment for renal dialysis patients were searched from PubMed, EMbase and Cochran Central Register of Controlled Trials. We screened relevant studies according to predefined inclusion and exclusion criteria, evaluated the quality of the included studies, and performed meta-analyses by using the Cochrane Collaboration's Revman 5.1 software.

RESULTS

We identified nine trials including 3098 patients. Meta-analysis showed statins can significantly decrease the serum C-reactive protein (CRP) (SMD, -0.54; 95% confidence interval (CI), -1.04 to -0.05; P = 0.03) and high sensitivity CRP (hs-CRP) level (SMD, -0.72; 95% CI, -1.14 to -0.31; P = 0.0007) of dialysis patients compared with that of the control group. However, statins did not differ significantly from the control group in increasing the serum Alb level (SMD, -0.13; 95% CI, -0.42 to 0.15; P = 0.37).

CONCLUSIONS

Statins can improve the chronic inflammation status reflected by the decreasing of serum CRP and hs-CRP levels, whereas there is no conclusive evidence that it can improve the nutrition status. However, this result needs to be further confirmed in more high-quality randomized clinical trials.

The effect of statin therapy on the formation of arteriovenous fistula stenoses and the rate of reoccurrence of previously treated stenoses

Statins reduce inflammation in end-stage renal disease patients and improve endothelial function beyond cholesterol lowering. Despite this, statins do not improve the maturation rate, primary patency rate, and the cumulative survival of arteriovenous fistulas (AVFs). It is unknown if statins decrease the number of stenoses developing in AVFs or prolong the intervals between angioplasties needed to treat recurring stenoses. We conducted a retrospective chart review of our 265 active dialysis patients. The statin group was significantly more likely to be diabetic (64% vs. 43.6%) and treated with aspirin (64% vs. 40%) when compared to those not treated with statins (P=0.04 and 0.01). The mean time to first intervention (primary patency) was 16.5 months in statin users and 15.8 months in the nonstatin group (P=0.49) with standard deviations of ± 18.5 and 16.6 months, respectively. Statin use was not associated with a significant decrease in the number of stenoses diagnosed (P=0.28). The mean time between recurrent stenoses' angioplasties was 8.9 months in statin users and 7.3 months in the nonstatin patients (P=0.25). Aspirin users were more likely to have a decreased primary patency (rate ratio=1.65, P=0.03) compared with nonaspirin users. Patients who were prescribed aspirin developed 1.6 (P 0.01) times more stenoses than those not treated with aspirin. We report for the first time that statin therapy does not decrease the number of stenotic lesions developing in the AVF or prolong the interval between procedures required to treat recurrent stenoses.

Benefits and harms of statin therapy for persons with chronic kidney disease: a systematic review and meta-analysis

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.

Comparison of serum albumin, serum C-reactive protein, and pulse wave velocity as predictors of the 4-year mortality of chronic hemodialysis patients

AIM

Although serum albumin and C-reactive protein (CRP) levels and pulse wave velocity (PWV) are known to be associated with the clinical outcome of hemodialysis (HD) patients, it is unknown which of these parameters are more predictive of the long-term mortality of such patients.

METHODS

We measured biochemical parameters, including serum albumin and CRP, and the PWV of 202 patients on maintenance HD therapy and followed their course for 4 years, and 186 of the patients were enrolled in the current study analyses. We divided the 186 patients into three tertiles according to their serum albumin and CRP levels and PWV values, and conducted multivariate analyses to examine the impact of the tertiles on 4-year mortality.

RESULTS

Twenty-three (12.4%) patients died during the follow-up period, and the serum albumin of the group that died was significantly lower than in the group that survived, but the CRP levels and PWV were significantly higher in the group that died. The results of Kaplan-Meier analyses revealed a significantly higher risk of all-cause mortality in HD patients with higher CRP based on the results of Cox proportional hazards analyses; however, the serum albumin and PWV values were not associated with all-cause mortality.

CONCLUSION

The results of this study suggest that serum CRP levels are a better mortality predictor than serum albumin or PWV values of chronic HD patients.

Inflammation and cachexia in chronic kidney disease

Chronic inflammation is associated with cachexia and increased mortality risk in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). Inflammation suppresses appetite and causes the loss of protein stores. In CKD patients, increased serum levels of pro-inflammatory cytokines may be caused by reduced renal function, volume overload, oxidative or carbonyl stress, decreased levels of antioxidants, increased susceptibility to infection in uremia, and the presence of comorbid conditions. Cachexia is brought about by the synergistic combination of a dramatic decrease in appetite and an increase in the catabolism of fat and lean body mass. Pro-inflammatory cytokines act on the central nervous system to alter appetite and energy metabolism and to provide a signal-through the nuclear factor-kappaB and ATP-ubiquitin-dependent proteolytic pathways-that causes muscle wasting. Further research into the molecular pathways leading to inflammation and cachexia may lead to novel therapeutic therapies for this devastating and potentially fatal complication of chronic disease.

Is systemic inflammation of hemodialysis patients improved with the use of enalapril? Results of a randomized, double-blinded, placebo-controlled clinical trial

This study compared the effect of enalapril versus placebo on serum tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, and C-reactive protein (CRP) in hemodialysis in a randomized, double- blinded, controlled clinical trial. Patients without infection or antiinflammatory drugs were randomly allocated to a study (n = 13, enalapril, 20 mg/day) or control (n = 12, placebo) group; all had arteriovenous fistula. Serum TNF-alpha, IL-6, and CRP were measured at 0, 1, and 3 months. Systolic blood pressure (baseline vs. final) was 151 +/- 25 vs. 135 +/- 19 mm Hg (p < 0.05) in the study group and 154 +/- 21 vs. 144 +/- 27 mm Hg in control group; diastolic blood pressure was 86 +/- 9 vs. 76 +/- 13 and 91 +/- 16 vs. 81 +/- 18 mm Hg, respectively; median (percentiles 25%-75%) IL-6 (baseline vs. final) was 4.2 (3-8) vs. 4.1 (2-9) pg/mL and 6.3 (3-9) vs. 6.7 (3-8) pg/mL; and CRP was 1.9 (1-7) vs. 3.0 (1-12) mg/L and 4.7 (1-16) vs. 3.9 (2-16) mg/L, respectively. TNF-alpha was detected in only two patients. Enalapril significantly reduced blood pressure in hemodialysis patients, but it did not decrease IL-6 and CRP compared with placebo.

Dyslipidemia in chronic kidney disease: managing a high-risk combination

Cardiovascular disease (CVD) is the single largest cause of mortality in patients with chronic kidney disease (CKD), with those patients having a 10-year CVD-related morbidity and mortality of > 20%. This has led to the inclusion of CKD as a CVD equivalent, and justifies the aggressive treatment of modifiable risk factors such as dyslipidemia. Primary care physicians (PCP) often manage patients with CKD in the early stages of the disease and have a pivotal role in affecting long-term outcomes in CKD patients related to cardiovascular and all-cause mortality. Therefore, treatment of dyslipidemia often becomes the responsibility of the PCP and comes with its own set of challenges because of CKD-related issues (eg, the dose adjustments required). Exacerbating this problem is the fact that current guidelines are lengthy and complex. This article discusses the current guidelines for treating dyslipidemia in patients with CKD. Few studies have examined the safety and efficacy of pharmacotherapy for treatment of dyslipidemia in the CKD population, and ongoing studies such as the Study of Heart and Renal Protection (SHARP) should help clarify the current treatment guidelines.

Short-term effect of simvastatin treatment on inflammatory parameters in peritoneal dialysis patients

OBJECTIVE

Increased serum pro-inflammatory cytokine levels are associated with an increased mortality rate in end-stage renal disease (ESRD) patients. Statins decrease cardiovascular mortality and serum C-reactive protein (CRP) levels in hemodialysis patients. As the anti-inflammatory effect of statins has not previously been studied in peritoneal dialysis (PD) patients with a non-inflammatory status, we wanted to investigate the anti-inflammatory effect of simvastatin in these patients.

MATERIAL AND METHODS

Forty-eight PD patients were randomly allocated to either simvastatin treatment (n=25) or placebo (n=23). Patients in the active-treatment group received simvastatin 20 mg/day for 1 month. At baseline and after 1 month of treatment, blood samples were drawn and high-sensitivity CRP, interleukin-6, tumor necrosis factor (TNF)-alpha and plasma lipid profiles were determined. These parameters were compared between the groups at baseline and at the end of the study period.

RESULTS

Twenty-five subjects in the treatment group and 20 in the placebo group completed the study. Three patients in the placebo group were excluded from the study due to the occurrence of bacterial peritonitis during the study period. Clinical characteristics and baseline parameters were similar in both groups. Serum total and low-density lipoprotein cholesterol levels, and triglyceride and serum TNF-alpha levels decreased significantly compared to baseline in the treatment group; there were no corresponding differences in the placebo group.

CONCLUSIONS

Simvastatin decreased the serum TNF-alpha level in PD patients with a non-inflammatory status. A decrease in the TNF-alpha level could be one of the possible mechanisms of the anti-atherogeneic effect of simvastatin. We suggest that different treatment strategies aimed at decreasing serum cytokine levels could be evaluated to decrease cardiovascular morbidity and mortality in the dialysis population.

HMG CoA reductase inhibitors (statins) for dialysis patients

BACKGROUND

Cardiovascular disease accounts for more than half the number of deaths among dialysis patients. The role of HMG CoA reductase inhibitors (statins) in the treatment of dyslipidaemia in dialysis patients is unclear and their safety has not been established.

OBJECTIVES

To assess the benefits and harms of statins in peritoneal dialysis (PD) and haemodialysis patients (HD).

SEARCH STRATEGY

We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled trials (CENTRAL, in The Cochrane Library), the Cochrane Renal Group's specialised register and handsearched reference lists of textbooks, articles and scientific proceedings.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs comparing statins with placebo, no treatment or other hypolipidaemic agents in dialysis patients.

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. The results were expressed as mean difference (MD) for continuous outcomes and risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CI).

MAIN RESULTS

Fourteen studies (2086 patients) compared statins versus placebo or other lipid lowering agents. Compared to placebo, statins did not decrease all-cause mortality (10 studies, 1884 patients; RR 0.95, 95% CI 0.86 to 1.06) or cardiovascular mortality (9 studies, 1839 patients: RR 0.96, 95% CI 0.65 to 1.40). There was a lower incidence of nonfatal cardiovascular events with statins compared to placebo in haemodialysis patients (1 study, 1255 patients; RR 0.86, 95% CI 0.74 to 0.99). Compared with placebo, statin use was associated with a significantly lower end of treatment average total cholesterol (14 studies, 1823 patients; MD -42.61 mg/dL, 95% CI -53.38 to -31.84), LDL cholesterol (13 studies, 1801 patients; MD -43.06 mg/dL, 95% CI -53.78 to -32.35) and triglycerides (14 studies, 1823 patients: MD -24.01 mg/dL, 95% CI -47.29 to -0.72). There was similar occurrence of rhabdomyolysis and elevated liver function tests with statins in comparison to placebo.

AUTHORS' CONCLUSIONS

Statins decreased cholesterol levels in dialysis patients similar to that of the general population. With the exception of one study, studies were of short duration and therefore the efficacy of statins in decreasing the mortality rate is still unclear. Statins appear to be safe in this high-risk population. Ongoing studies should provide more insight about the efficacy of statins in reducing mortality rates in dialysis patients.

HMG CoA reductase inhibitors (statins) for dialysis patients

BACKGROUND

Cardiovascular disease accounts for more than half the number of deaths among dialysis patients. The role of HMG CoA reductase inhibitors (statins) in the treatment of dyslipidaemia in dialysis patients is unclear and their safety has not been established.

OBJECTIVES

To assess the benefits and harms of statins in peritoneal dialysis (PD) and haemodialysis patients (HD).

SEARCH STRATEGY

We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled trials (CENTRAL, in The Cochrane Library), the Cochrane Renal Group's specialised register and handsearched reference lists of textbooks, articles and scientific proceedings.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs comparing statins with placebo, no treatment or other hypolipidaemic agents in dialysis patients.

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. The results were expressed as mean difference (MD) for continuous outcomes and risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CI).

MAIN RESULTS

Fourteen studies (2086 patients) compared statins versus placebo or other lipid lowering agents. Compared to placebo, statins did not decrease all-cause mortality (10 studies, 1884 patients; RR 0.95, 95% CI 0.86 to 1.06) or cardiovascular mortality (9 studies, 1839 patients: RR 0.96, 95% CI 0.65 to 1.40). There was a lower incidence of nonfatal cardiovascular events with statins compared to placebo in haemodialysis patients (1 study, 1255 patients; RR 0.86, 95% CI 0.74 to 0.99). Compared with placebo, statin use was associated with a significantly lower end of treatment average total cholesterol (14 studies, 1823 patients; MD -42.61 mg/dL, 95% CI -53.38 to -31.84), LDL cholesterol (13 studies, 1801 patients; MD -43.06 mg/dL, 95% CI -53.78 to -32.35) and triglycerides (14 studies, 1823 patients: MD -24.01 mg/dL, 95% CI -47.29 to -0.72). There was similar occurrence of rhabdomyolysis and elevated liver function tests with statins in comparison to placebo.

AUTHORS' CONCLUSIONS

Statins decreased cholesterol levels in dialysis patients similar to that of the general population. With the exception of one study, studies were of short duration and therefore the efficacy of statins in decreasing the mortality rate is still unclear. Statins appear to be safe in this high-risk population. Ongoing studies should provide more insight about the efficacy of statins in reducing mortality rates in dialysis patients.

Endogenous tissue plasminogen activator and risk of recurrent cardiac events after an acute coronary syndrome in the MIRACL study

OBJECTIVE

To examine the relationship of baseline tissue plasminogen activator (t-PA) to early cardiovascular risk after an acute coronary syndrome, and the effect of intensive statin therapy.

METHODS

We measured plasma t-PA in 2860 of the 3086 (93%) subjects in the MIRACL study, an international randomized trial of atorvastatin 80mg daily versus placebo in patients with acute coronary syndromes. The relationship of t-PA to death, non-fatal acute myocardial infarction, cardiac arrest, or worsening angina over 16 weeks was assessed by Cox Proportional Hazards. D-dimer was measured in a random sample of 395 subjects.

RESULTS

Higher baseline t-PA was significantly related to the risk of recurrent events (HR=1.25, p=0.0014). This relationship was unaffected by adjustment for age, sex, troponin, hsCRP, and lipids (HR=1.17, p=0.029), but was attenuated by adjustment including body mass index and smoking (HR=1.14, p=0.08). D-dimer and t-PA concentrations were not related. Atorvastatin reduced the risk of recurrent events, but did not affect t-PA or D-dimer concentrations or the relationship of t-PA to outcomes.

CONCLUSION

In patients with acute coronary syndromes, increasing t-PA concentration was related to a higher early risk of recurrent events, paradoxically reflecting impaired endogenous fibrinolysis. This relationship is due in part to the association of t-PA with age, body mass index and smoking. Although statins lower the risk of recurrent events after acute coronary syndromes, it is unlikely that this benefit is achieved through thrombolytic and fibrinolytic pathways.

Lipid management in chronic kidney disease, hemodialysis, and transplantation

Recent studies have shown the spectrum of dyslipidemia in patients who have chronic kidney disease (CKD) or end-stage renal disease to be different from that of the general population. This article discusses the pathophysiology of dyslipidemia in CKD, dialysis, and renal transplant patients, the therapeutic options, and their association with clinical outcomes. Whenever possible, comparisons are made to outcomes in the general population.