There is a clear relationship between the rate of cardiovascular events and mortality and the loss of renal function. On the one hand, the illness cardiovascular is the leading cause of death in patients with chronic kidney diseaseand on the other hand, having chronic kidney disease increases your risk of dying from cardiovascular disease, whether or not you have other risk factors.

Dialysis patients have a mortality rate up to 40 times higher than the general population. In these cases, the cardiovascular disease is responsible for more than 50% of these deaths. Decreased glomerular filtration in adults is a factor of cardiovascular risk independent. Cardiovascular mortality in patients with chronic kidney disease in stages 3 and 4 it is two or three times greater than in patients with normal renal function.

Patients with cardiovascular disease established and decreased renal function.

recommendations

In the European guidelines for the management of dyslipidemias is qualified as high cardiovascular risk for matters with chronic kidney disease in phase 3 and from very high cardiovascular risk those of stage 4-5 or dialysis, without the need to apply risk estimation scales.

In this context, it should be taken into account that in all stages of chronic kidney disease, the prevalence of dyslipidemia is very high, so there is an inverse correlation between glomerular filtration rate and dyslipidemia. In fact, between 60% and 80% of patients with chronic kidney disease have some degree of dyslipidemia.

lipid profile

O chronic kidney disease causes important changes in lipoproteins from the early stages of the disease that precede changes in plasma lipids.

In patients with chronic kidney disease Cholesterol levels do not always show a linear relationship with cardiovascular events, as occurs in the general population. In fact, there is an inverse relationship in dialysis patients, where lower LDL-C levels are associated with a worse prognosis.

The absolute values ​​of LDL are similar to those of the population without kidney disease, however, its composition is different. On the one hand, LDL molecules are oxidized due to the pro-oxidant and pro-inflammatory environment of kidney disease, particularly in patients with chronic kidney disease in more advanced stages, on the other hand, LDL particles in the chronic kidney disease they are smaller, increasing their diffusion capacity in the arterial wall and, therefore, their atherogenic power.

The association of changes in the lipid profile with cardiovascular events it is most evident with high VLDL and LDL levels or low HDL values, but unlike the general population, not with triglycerides.

The lipid profile in dialysis patients is more complex because malnutrition and inflammation can lead to low values ​​of total cholesterol and LDL-C.

combined regime

The European guide to the management of dyslipidemias recommended with grade of recommendation 1, level of evidence A starting treatment with a statin or the combination of statin and ezetimiberegardless of LDL-C levels in patients over 50 years of age with chronic kidney disease in stages 3 to 5.

In patients with chronic kidney disease stage 5 in dialysis, it is suggested that the statins or the combination statin and ezetimibe do not administer initially if the patient has not previously received statins, regardless of cLDL levels. However, if they have already been treated with this regimen before starting dialysis, it is recommended that they continue with it.

start of combination

The best time to start rosuvastatin in conjunction with ezetimibe It is the moment when the reality of the patient and his cardiovascular risk is known. Most patients with chronic kidney disease are patients of very high cardiovascular risk.

The use of statins or the association of statin with ezetimibe it is required in patients with advanced renal disease, including dialysis, and established cardiovascular disease. However, there is still some controversy regarding the use of statins It is ezetimibe in these patients when there is no associated cardiovascular disease.

scientific evidence

In a meta-analysis, an exhaustive review of clinical studies conducted between 1970 and November 2011, including 31 studies with 48,429 patients with chronic kidney disease. A total of 6,690 major cardiovascular events and 6,653 deaths were detected.

treatment with statins reduced the relative risk of 23% in major cardiovascular events, 18% in coronary events, and 9% in cardiovascular or all-cause deaths.

The most important finding of this review is that the beneficial effect of statins It is closely linked to kidney function. The observed beneficial effects appear to be less in stage 5 patients and those requiring dialysis.

For the elaboration of this article, we had the collaboration of the physicians specialists in Primary Care Iker López Garciarena, Mercedes Lasa Garmendia and Ana María Murguizu García, the endocrinologist Jorge Pablo Hernández Hernández and the cardiologists Irene Rilo Miranda and Bernardo Ángel Serra.