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

2. Outline The relationship between CVD & CKD NKF-KDOQI guidelines ATP III guidelines Class effect of statin in CKD ? Safety & Dose Modification

3. LIP-FM-1011020 Epidemiology of CKD in Taiwan Lancet 2008

4. LIP-FM-1011020 Relationship Between Estimated GFR (eGFR) and Clinical Outcomes Go AS et al. N Engl J Med. 2004;351:1296-1305. Age-standardized event rate (per 100 person-yr) Death from any causeCardiovascular eventsAny hospitalization Total events = 51,424Total events = 139,011Total events = 554,651 Kaiser Permanente Renal Registry, n=1,120,295 adults aged  20 years Median follow-up = 2.84 years eGFR (mL/min/1.73 m 2 ) LIP-FM-1011020

5. Causes of death among period prevalent patients 1997–1999, treated with hemodialysis, peritoneal dialysis, or kidney transplantation.

6. Epidemiological Features of CKD in Taiwan AJKD 2007;49:46-55 －－ 1.000 No atherosclerotic vascular <0.0013.134-3.3723.251 Atherosclerotic vascular disease † －－ 1.000 No hyperlipidemia <0.0013.341-3.6053.471 Hyperlipidemia －－ 1.000 No hypertension <0.0013.757-4.0313.892 Hypertension －－ 1.000 No diabetes <0.0014.528-4.8944.707 Diabetes Comorbidity P95% CICrude OR Crude ORs for the Development of CKD, From 1997 to 2003 LIP-FM-1011020

10. 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)

11. Total cholesterol = LDL +HDL +TG/5

12. the results of lipid-lowering trials are usually generalizable to population subgroups.

15. 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) 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 non- HDL cholesterol to <130 mg/dL (<3.36 mmol/L). (C)

17. Summary

18. ATP III guideline LDL Cholesterol Goals and Cutpoints for Therapeutic Lifestyle Changes (TLC) & Drug Therapy Risk Category LDL Goal (mg/dL) LDL Level at Which to Initiate Therapeutic Lifestyle Changes (TLC) (mg/dL) LDL Level at Which to Consider Drug Therapy (mg/dL) CHD or CHD Risk Equivalents (10-year risk >20%) <100  100  130 (100–129: drug optional) 2+ Risk Factors (10-year risk  20%) <130  130 10-year risk 10–20%:  130 10-year risk <10%:  160 0–1 Risk Factor<160  160  190 (160–189: LDL- lowering drug optional)

23. Class effect of statin in CKD ?

24. 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 CKD Subgroup

25. 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."

29. JACC 2008 51(25) 2375-84

31. 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. Case 1

34. Final angiography

35. 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

37. 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

40. Case 4 72 year-old man HL, DM, CKD (stage 3) Unstable angina