Fluvastatin in the treatment of dyslipidemia associated with chronic kidney failure and renal transplantation

Lipid abnormalities in kidney disease and management strategies

Patients with kidney diseases continue to experience significant cardiovascular disease (CVD) morbidity and mortality. Although there are many important risk factors playing a role in the pathogenesis of CVD in chronic kidney disease (CKD) patients, dyslipidemia (elevated triglycerides, elevated oxidized low-density lipoprotein and low/dysfunctional low high-density) represents one of the modifiable risk factors. Renal failure patients have unique lipid abnormalities which not only have complex role in pathogenesis of CVD but also cause relative resistance to usual interventions. Most of the randomized trials have been in hemodialysis population and data from CKD non-dialysis, peritoneal dialysis and renal transplant populations is extremely limited. Compared to general population, evidence of mortality benefit of lipid lowering medications in CKD population is scarce. Future research should be directed towards establishing long term benefits and side effects of lipid lowering medications, through randomized trials, in CKD population.

Comparative efficacy and adverse effects of the addition of ezetimibe to statin versus statin titration in chronic kidney disease patients

BACKGROUND AND OBJECTIVES

The recent SHARP trial clearly demonstrated that a reduction in low-density lipoprotein (LDL) cholesterol with a daily regimen of simvastatin plus ezetimibe safely reduced the incidence of major atherosclerotic events in patients with chronic kidney disease (CKD). We aimed to compare the efficacy of and adverse effects from statin uptitration versus statin in combination with ezetimibe since only a few studies have addressed this question.

METHODS

This was a randomized, open-label, multicenter trial that included 286 patients with CKD whose LDL cholesterol levels were not reduced below 120 mg/dl despite a minimum dose of statin therapy. Patients received double doses of statin or usual statin dose with the addition of ezetimibe 10 mg daily. The observation period was 1 year during which time patients were checked regularly in clinic for adverse effects as well as for usual laboratory examinations. The key prespecified outcome was the incidence of adverse effects, which included skeletal muscle complaints, myalgia, muscle weakness, and muscle cramps with and without elevated CK levels. Increases in alanine transaminase (ALT) or aspartate transaminase (AST) levels >2 times the upper limit of normal (ULN) were considered clinically significant adverse effects.

RESULTS

Adverse events occurred in 9/145 in the combination group and in 24/141 in the statin uptitration group (p < 0.01). Moreover, in patients with CKD of stages 3-5, rates were 6/58 in the combination group versus 20/52 in the statin uptitration group (p < 0.01). No serious adverse effects such as rhabdomyolysis were noted in either group. Serum creatinine levels remained essentially unchanged in both groups except in CKD stages 4 and 5. Reductions in LDL cholesterol were similar between the two groups at the start of and at the end of the study. During the study, no atherosclerotic events were reported in either group.

CONCLUSION

When statin uptitration produces adverse effects such as myopathy, combination therapy with ezetimibe is recommended instead of statin alone.

Managing dyslipidemia in chronic kidney disease

The incidence of chronic kidney disease (CKD) in the U.S. continues to increase, and now over 10% of the U.S. population has some form of CKD. Although some patients with CKD will ultimately develop renal failure, most patients with CKD will die of cardiovascular disease before dialysis becomes necessary. Patients with CKD have major proatherogenic lipid abnormalities that are treatable with readily available therapies. The severe derangements seen in lipoprotein metabolism in patients with CKD typically results in high triglycerides and low high-density lipoprotein (HDL) cholesterol. Because of the prevalence of triglyceride disorders in patients with CKD, after treating patients to a low-density lipoprotein goal, non-HDL should be calculated and used as the secondary goal of treatment. A review of the evidence from subgroup analysis of several landmark lipid-lowering trials supports treating dyslipidemia in mild to moderate CKD patients with HMG-CoA reductase inhibitors. The evidence to support treating dyslipidemia in hemodialysis patients, however, has been mixed, with several outcome trials pending. Patients with CKD frequently have mixed dyslipidemia and often require treatment with multiple lipid-lowering drugs. Although statins are the cornerstone of therapy for most patients with CKD, differences in their pharmacokinetic properties give some statins a safety advantage in patients with advanced CKD. Although most other lipid-lowering agents can be used safely with statins in combination therapy in patients with CKD, the fibrates are renally metabolized and require both adjustments in dose and very careful monitoring due to the increased risk of rhabdomyolysis. After reviewing the safety and dose alterations required in managing dyslipidemia in patients with CKD, a practical treatment algorithm is proposed.

Long-term cardiac outcomes in renal transplant recipients receiving fluvastatin: the ALERT extension study

Renal transplant recipients (RTR) have an increased risk of premature cardiovascular disease. The ALERT study is the first trial to evaluate the effect of statin therapy on cardiac outcomes following renal transplantation. Patients initially randomized to fluvastatin or placebo in the 5-6 year ALERT study were offered open-label fluvastatin XL 80 mg/day in a 2-year extension to the original study. The primary endpoint was time to first major adverse cardiac event (MACE). Of 1787 patients who completed ALERT, 1652 (92%) were followed in the extension. Mean total follow-up was 6.7 years. Mean LDL-cholesterol was 98 mg/dL (2.5 mmol/L) at last follow-up compared to a pre-study level of 159 mg/dL (4.1 mmol/L). Patients randomized to fluvastatin had a reduced risk of MACE (hazards ratio [HR] 0.79, 95% CI 0.63-0.99, p = 0.036), and a 29% reduction in cardiac death or definite non-fatal MI (HR 0.71, 95% CI 0.55-0.93, p = 0.014). Total mortality and graft loss did not differ significantly between groups. Fluvastatin produces a safe and effective reduction in LDL-cholesterol associated with reduced risk of MACE in RTR. The lipid-lowering and cardiovascular benefits of fluvastatin are comparable to those of statins in other patient groups, and support use of fluvastatin in RTR.