Transcript 投影片 1

Update Lipid Management in
Chronic Kidney Disease
成大醫院心臟內科
李政翰醫師
助理教授
Outline
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The relationship between CVD & CKD
NKF-KDOQI guidelines
ATP III guidelines
Class effect of statin in CKD ?
Safety & Dose Modification
Epidemiology of CKD in Taiwan
Lancet 2008
LIP-FM-1011020
Age-standardized event rate (per 100 person-yr)
Relationship Between Estimated GFR (eGFR) and
Clinical Outcomes
Death from any cause
Cardiovascular events
Any hospitalization
Total events = 51,424
Total events = 139,011
Total events = 554,651
eGFR (mL/min/1.73 m2)
Kaiser Permanente Renal Registry, n=1,120,295 adults aged 20 years
Median follow-up = 2.84 years
Go AS et al. N Engl J Med. 2004;351:1296-1305.
LIP-FM-1011020
LIP-FM-1011020
Causes of death among period prevalent patients 1997–1999, treated
with hemodialysis, peritoneal dialysis, or kidney transplantation.
Epidemiological Features of CKD in Taiwan
Crude ORs for the Development of CKD, From 1997 to 2003
Crude OR
95% CI
P
Comorbidity
Diabetes
4.707
4.528-4.894
<0.001
No diabetes
1.000
－
－
Hypertension
3.892
3.757-4.031
<0.001
No hypertension
1.000
－
－
Hyperlipidemia
3.471
3.341-3.605
<0.001
No hyperlipidemia
1.000
－
－
Atherosclerotic vascular disease†
3.251
3.134-3.372
<0.001
No atherosclerotic vascular
1.000
－
－
AJKD 2007;49:46-55
LIP-FM-1011020
LIP-FM-1011020
LIP-FM-1011020
LIP-FM-1011020
KDOQI Clinical Practice Guidelines
Managing Dyslipidemias in Chronic Kidney Disease
• Guideline 1
1.1. All adults and adolescents with CKD should be
evaluated for dyslipidemias. (B)
• 1.2. For adults and adolescents with CKD, the
assessment of dyslipidemias should include a
complete fasting lipid profile with total cholesterol,
LDL, HDL, and triglycerides. (B)
• 1.3. For adults and adolescents with Stage 5 CKD,
dyslipidemias should be evaluated upon
presentation, at 2–3 months after a change in
treatment or other conditions known to cause
dyslipidemias; and at least annually thereafter. (B)
Total cholesterol = LDL +HDL +TG/5
the results of lipid-lowering trials are usually
generalizable to population subgroups.
Treatment of Adults With
Dyslipidemias
• 4.1. For adults with Stage 5 CKD and fasting triglycerides 500
mg/dL ( 5.65 mmol/L) that cannot be corrected by removing an
underlying cause, treatment with therapeutic lifestyle changes
(TLC) and a triglyceride-lowering agent should be considered.
(C)
• 4.2. For adults with Stage 5 CKD and LDL 100 mg/dL ( 2.59
mmol/L), treatment should be considered to reduce LDL to <100
mg/dL (<2.59 mmol/L). (B)
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• 4.3. For adults with Stage 5 CKD and LDL <100 mg/dL (<2.59
mmol/L), fasting triglycerides 200 mg/dL ( 2.26 mmol/L), and
non-HDL cholesterol (total cholesterol minus HDL) 130 mg/dL
( 3.36 mmol/L), treatment should be considered to reduce nonHDL cholesterol to <130 mg/dL (<3.36 mmol/L). (C)
Summary
ATP III guideline
LDL Cholesterol Goals and Cutpoints for
Therapeutic Lifestyle Changes (TLC) & Drug Therapy
Risk Category
CHD or CHD Risk
Equivalents
(10-year risk >20%)
2+ Risk Factors
(10-year risk 20%)
0–1 Risk Factor
LDL Goal
(mg/dL)
<100
LDL Level at Which
to Initiate
Therapeutic
Lifestyle Changes
(TLC) (mg/dL)
LDL Level at Which
to Consider
Drug Therapy
(mg/dL)
100
130
(100–129: drug
optional)
10-year risk 10–20%:
130
<130
130
10-year risk <10%:
160
<160
160
190
(160–189: LDLlowering drug
optional)
Class effect of statin in CKD ?
CKD Subgroup
PLANET I : Prospective evaLuation of proteinuriA and
reNal function in diabETic patients with progressive renal
disease
de Zeeuw D. 2010European Renal Association-European Dialysis and Transplant Association Congress;
June 27, 2010; Munich, Germany.
LIP-FM-1011020
For PLANET I (diabetic patients),
de Zeeuw summarized:
• "Atorvastatin significantly reduces the proteinuria in
these patients on top of ACE/ARB therapy, with
around a 15% reduction in proteinuria, whereas
rosuvastatin, both 10 and 40 mg, had no significant
effect at all on proteinuria."
JACC 2008 51(25) 2375-84
Case 1
• 82 year-old man
• CAD/TVD, HTN, HL, CKD (stage 4)
• Presented with cyanosis of both feet toes
in progression and gangrene change of
right toes now
• CTA showed severe and diffuse calcified
both CFA and SFA , suspect CTO at right
SFA proximal part.
Final angiography
Case 2
• 66 year-old
• Heavy smoker
• HTN with adalat OROS 2# bid, lasix 1#qd, doxaben
1#qd, imdur 1#qd, concor 1#qd  BP 170/100
mmHg
• CKD (Cr: 3.5mg/dl, stage 4)
• HL
• Vertebrobasilar insufficiency
• CAD/TVD post PCI
• Bilateral ICA stenosis post CAS
• Renal echo: right: 7.5cm, left : 9.2cm, no
hydronephrosis
Case 3
• 82 year-old man
• CC: right hemaparesis and slurred speech in the
recent 6 months
• Risk factors: HTN, hyperlipidemia
• Repeated transient slurred speech and right
hemiparesis recently ; obvious claudication of both
lower extremities post 2-minute walking.
• Cre: 1.4 mg/dl (CKD stage 3)
cholesterol: 185 mg/dl
TG: 179 mg/dl
LDL: 98 mg/dl
HDL: 45 mg/dl
Case 4
• 72 year-old man
• HL, DM, CKD (stage 3)
• Unstable angina