Marcello Tonelli, MD, SM; Christoph Wanner, MD; for the Kidney Disease: Improving Global Outcomes Lipid Guideline Development Work Group Members (*)
Acknowledgment: The authors thank the KDIGO co-chairs Bertram L. Kasiske and David C. Wheeler; the evidence review team (Ashish> Upadhyay, Ethan Balk, Amy Earley, Shana Haynes, and Jenny Lamont) and Michael Cheung; and all those who provided feedback during the public review of the draft guideline.
Financial Support: KDIGO is supported by a consortium of sponsors, and no funding is accepted for the development of specific guidelines. KDIGO's founding sponsor is the National Kidney Foundation. Support for KDIGO is also provided by Abbott, Amgen, Bayer Schering Pharma, Belo Foundation, Bristol-Myers Squibb, Chugai Pharmaceutical, Coca-Cola Company, Dole Food Company, Fresenius Medical Care, Genzyme, Hoffmann-LaRoche, International Society of Nephrology, JC Penney, Kyowa Hakko Kirin, NATCO–The Organization for Transplant Professionals, National Kidney Foundation (NKF)-Board of Directors, Novartis, Pharmacosmos, PUMC Pharmaceutical, Robert and Jane Cizik Foundation, Shire, Takeda Pharmaceutical, Transwestern Commercial Services, Vifor Pharma, and Wyeth.
Grant Support: Dr. Tonelli was supported by an AHFMR Population Health Scholar award and a Government of Canada Research Chair in the optimal care of persons with chronic kidney disease.
Potential Conflicts of Interest: Dr. Tonelli reports consultancy and speaker honoraria for Merck that were donated to charity. Dr. Wanner reports speaker honoraria from Astellas-Pfizer (Japan), Merck, and Merck Sharpe & Dohme. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-2453.
Corresponding Author: Marcello Tonelli, MD, SM, 7-129 CSB, University of Alberta, 8440 112 Street NW, Edmonton, Alberta, T6B 2G3 Canada; e-mail, email@example.com.
Current Author Addresses: Dr. Tonelli: 7-129 CSB, University of Alberta, 8440 112 Street NW, Edmonton, Alberta, T6B 2G3 Canada.
Dr. Wanner: Division of Nephrology, Department of Medicine, University Hospital of Würzburg and the Comprehensive Heart Failure Center, Oberdürrbacherstr 2, 97080 Wörzburg, Germany.
Author Contributions: Drafting of the article: M. Tonelli, C. Wanner.
Critical revision of the article for important intellectual content: M. Tonelli, C. Wanner.
Final approval of the article: M. Tonelli, C. Wanner.
The Kidney Disease: Improving Global Outcomes (KDIGO) organization developed a clinical practice guideline in 2013 on lipid management and treatment of all adults and children with chronic kidney disease (CKD). All forms of CKD are included (non–dialysis-dependent, dialysis-dependent, and kidney transplant recipients).
The KDIGO Lipid Guideline Development Work Group defined the scope of the guideline, gathered evidence, determined topics for systematic review, and graded the quality of evidence that had been summarized by an evidence review team. Searches of the English-language literature were conducted through August 2011 and supplemented by targeted searches through June 2013. Final modification of the guidelines was informed by the KDIGO Board of Directors and a public review process involving registered stakeholders.
The full guideline includes 13 recommendations; a key element was the recommendation for statin or statin with ezetimibe treatment of adults aged 50 years or older with estimated glomerular filtration rates less than 60 mL/min/1.73 m2 but not treated with long-term dialysis or kidney transplantation. This synopsis focuses on 8 recommendations pertinent to assessment of lipid status and treatment with a statin-based regimen in adults.
Appendix Table 1. GRADE Criteria Used for Grading the Strength of Recommendation in the KDIGO Lipid Guideline
Appendix Table 2. GRADE Criteria Used for Grading the Overall Quality of Evidence in the KDIGO Lipid Guideline
Appendix Table 3. Topics Chosen for Systematic Review and Screening Criteria
Prognosis of CKD chronic kidney disease by GFR and albuminuria categories: KDIGO 2012.
Chronic kidney disease is defined as abnormalities of kidney structure or function, present for >3 mo, with implications for health. Chronic kidney disease is classified based on cause, GFR category (G1–G5), and albuminuria category (A1–A3), abbreviated as CGA. Green means low risk (if no other markers of kidney disease, no CKD), yellow means moderately increased risk, orange means high risk, and red means very high risk. ACR = albumin–creatinine ratio; GFR = glomerular filtration rate.
Appendix Table 4. Risk for Coronary Death or Nonfatal MI, by Age and eGFR*
Algorithm for cholesterol-lowering treatment in persons with CKD.
Boxes represent recommendations about whether to prescribe a statin regimen. Boxes with dark and medium green fill represent strong recommendations; lighter green and white boxes represent weak recommendations. Recommended statin regimens are shown in Table 1 and include statin monotherapy or statin/ezetimibe for those with CKD stage 3a to 5 and statin monotherapy for all other CKD populations. CKD = chronic kidney disease; HD = hemodialysis; PD = peritoneal dialysis.
Table 1. Recommended Doses of Statins in Adults With Chronic Kidney Disease*
2.1.1: In adults aged ≥50 years with eGFR <60 ml/min/1.73 m2 but not treated with chronic dialysis or kidney transplantation (GFR categories G3a–G5), we recommend treatment with a statin or statin/ezetimibe combination. (1A)
2.1.2: In adults aged ≥50 years with CKD and eGFR ≥60 ml/min/1.73 m2 (GFR categories G1–G2), we recommend treatment with a statin. (1B)
2.2: In adults aged 18–49 years with CKD but not treated with chronic dialysis or kidney transplantation, we suggest statin treatment in people with one or more of the following (2A):
Known coronary disease (myocardial infarction or coronary revascularization)
Prior ischemic stroke
Estimated 10-year incidence of coronary death or non-fatal myocardial infarction >10%
2.3.1: In adults with dialysis-dependent CKD, we suggest that statins or statin/ezetimibe combination not be initiated. (2A)
2.3.2: In adults already receiving statins or statin/ezetimibe combination at the time of dialysis initiation, we suggest that these agents be continued. (2C)
2.4: In adult kidney transplant recipients, we suggest treatment with a statin. (2B)
1.1: In adults with newly identified CKD (including those treated with chronic dialysis or kidney transplantation), we recommend evaluation with a lipid profile (total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides). (1C)
Table 2. Secondary Causes of Dyslipidemia*
1.2: In adults with CKD (including those treated with chronic dialysis or kidney transplantation), follow-up measurement of lipid levels is not required for the majority of patients. (Not Graded)
Table 3. Examples of Situations in Which Measuring Cholesterol Levels May or May Not Change Patient Management
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Steward St. Elizabeth's Medical Center
February 10, 2014
Conflict of Interest:
Associate Editor - ACP Journal Club
HIV Patients with CKD and HAART Treatment
The long awaited guidelines for lipid management in chronic kidney disease (CKD) patients by Tonelli et al (1) are extremely useful to the practicing nephrologist. HIV patients with especially on highly active anti-retroviral treatment (HAART) treatment has higher incidence of dyslipidemia and cardiovascular disease. In addition, these patients tends to be young and hence the life time risk for CAD remains high. Though there is paucity of hard end-point data on treatment with lipid lowering agents in HAART treated CKD patients. It would be nice to amend the guidelines to include heightened vigilance to check lipids and appropriate treatment with pravastatin or atorvastatin to minimize drug interaction (1).Tejas Patel, MD, MPH, FACP, FASNSteward St. Elizabeth's Medical CenterBrighton, MA 02135Reference:1. Tonelli M, Wanner C for the Lipid Management in Chronic Kidney Disease: Improving Global Outcomes Lipid Guideline Development Work Group Members. Lipid Management in Chronic Kidney Disease: Synopsis of the Kidney Disease: Improving Global Outcomes 2013 Clinical Practice Guideline. Ann Intern Med. 2013 Dec 10. doi: 10.7326/M13-24532. Dubé MP, Stein JH, Aberg JA, Fichtenbaum CJ et al; Adult AIDS Clinical Trials Group Cardiovascular Subcommittee; HIV Medical Association of the Infectious Disease Society of America. Guidelines for the evaluation and management of dyslipidemia in human immunodeficiency virus (HIV)-infected adults receiving antiretroviral therapy: recommendations of the HIV Medical Association of the Infectious Disease Society of America and the Adult AIDS Clinical Trials Group, Clin Infect Dis. 2003 Sep 1;37(5):613-27
Tonelli M, Wanner C, for the Kidney Disease: Improving Global Outcomes Lipid Guideline Development Work Group Members. Lipid Management in Chronic Kidney Disease: Synopsis of the Kidney Disease: Improving Global Outcomes 2013 Clinical Practice Guideline. Ann Intern Med. 2014;160:182-189. doi: 10.7326/M13-2453
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Published: Ann Intern Med. 2014;160(3):182-189.
Cardiology, Chronic Kidney Disease, Coronary Risk Factors, Dyslipidemia, Guidelines.
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