Low statin use in nondialysis-dependent chronic kidney disease in the absence of clinical atherosclerotic cardiovascular disease or diabetes

Background

Both reduced glomerular filtration rate and increased urine albumin excretion, markers of chronic kidney disease (CKD), are associated with increased risk of atherosclerotic cardiovascular disease (ASCVD). However, CKD is not recognized as an ASCVD risk equivalent by most lipid guidelines. Statin medications, especially when combined with ezetimibe, significantly reduce ASCVD risk in patients with nondialysis-dependent CKD. Unless physicians recognize the heightened ASCVD risk in this population, statins may not be prescribed in the absence of clinical cardiovascular disease or diabetes, a recognized ASCVD risk equivalent. We examined statin use in adults with nondialysis-dependent CKD and examined whether the use differed in the presence of clinical ASCVD and diabetes.

Methods

This study ascertained statin use from pharmacy dispensing records during fiscal years 2012 and 2013 from the US Department of Veterans Affairs Healthcare System. The study included 581 344 veterans aged ≥50 years with nondialysis-dependent CKD Stages 3-5 with no history of kidney transplantation or dialysis. The 10-year predicted ASCVD risk was calculated with the pooled risk equation.

Results

Of veterans with CKD, 62.1% used statins in 2012 and 55.4% used statins continuously over 2 years (2012-13). Statin use in 2012 was 76.2 and 75.5% among veterans with CKD and ASCVD or diabetes, respectively, but in the absence of ASCVD, diabetes or a diagnosis of hyperlipidemia, statin use was 21.8% (P < 0.001). The 10-year predicted ASCVD risk was ≥7.5% in 95.1% of veterans with CKD, regardless of diabetes status.

Conclusions

Statin use is low in veterans with nondialysis-dependent CKD in the absence of ASCVD or diabetes despite high-predicted ASCVD risk. Future studies should examine other populations.

Statin use among Veterans with dialysis-dependent chronic kidney disease

INTRODUCTION

The benefits of statin medications in patients receiving maintenance dialysis remains controversial and clinical trials overall have shown no benefit. Potential side effects of statin medications include myalgias, myopathy, and memory loss and risk of side effects associated with statin medications increase with higher statin doses. We examined statin use and statin dose among Veterans with dialysis dependent CKD. Such information may help clinicians modulate medication use and reduce pill burden in appropriate patients.

METHODS

This cross-sectional analysis ascertained medication utilization by linking records from the U.S. Department of Veteran's Affairs (VA) Managerial Cost Accounting Pharmacy National Data Extracts and Medicare Part D during calendar year 2013 for Veterans with dialysis-dependent CKD enrolled in and/or using VA healthcare. The venue of dialysis and patient characteristics were ascertained by linking VA Medical SAS datasets, VA Fee Basis datasets (for non-VA care paid for by VA), Medicare claims and the United States Renal Data Systems patient core files.

FINDINGS

We identified 18,494 Veterans with dialysis-dependent CKD who were enrolled in and/or used VA healthcare, had no history of kidney transplantation, and were alive on January 1, 2014. More than half (58.1%) of Veterans with dialysis-dependent CKD used statins and 35.7% of statin utilization was high dose. Statins were the third most commonly prescribed medication after beta blockers (64.8%) and phosphate binders (64.5%).

DISCUSSION

Statins are a commonly prescribed medication among Veterans receiving maintenance dialysis and approximately one-third of statin utilization is high dose in this population. Future studies should examine patient preferences, comorbidities, and dialysis characteristics that impact the risks and benefits of statin use in order to identify those patients who will or will not benefit from continued statin use.