Impact of Dyslipidemia in End-Stage Renal Disease

Abstract

Abstract. Heart disease is a major cause of morbidity and mortality among patients with renal failure. Premature atherosclerotic coronary heart disease is driven by multiple risk factors, including dyslipidemia and oxidative stress. In the nondialysis population, there is overwhelming evidence that treatment of dyslipidemia can significantly improve cardiovascular outcomes. Accumulating data indicate that dialysis patients have atherogenic lipid abnormalities. Although LDL cholesterol (LDL-C) levels in patients who undergo hemodialysis are normal or near normal, increased oxidized LDL-C, triglycerides, and lipoprotein (a) [Lp(a)]; decreased HDL cholesterol (HDL-C); and triglyceride-rich VLDL have been noted. Patients who receive peritoneal dialysis have a more atherogenic lipid profile with increased LDL-C, apolipoprotein B, oxidized LDL-C, triglycerides, and Lp(a) and decreased HDL-C. Furthermore, the LDL particles of peritoneal dialysis patients are small and dense. However, there is a dearth of information regarding the goals, efficacy, and safety of dyslipidemia treatment among dialysis patients. Given the strong evidence of risk reduction and the benefits of lipid-lowering treatment in the nondialysis population, the emerging consensus is that dialysis patients should be treated aggressively for dyslipidemia to an LDL-C goal below 100 mg/dl. Although physicians and patients may be reluctant to add medications because of concerns about polypharmacy, potential decreased compliance, and increased cost, the use of agents such as sevelamer that can serve multiple functions, including phosphate control, lipid lowering (decreased LDL-C and total cholesterol), and anti-inflammatory effects (decreased high-sensitivity C-reactive protein), should be explored and considered for patients who would benefit from such treatment.

Lipid Abnormalities and Oxidized LDL in Chronic Kidney Disease Patients on Hemodialysis and Peritoneal Dialysis

“…This is in accordance with other reports, which show that patients with end-stage renal disease have low levels of HDL-C and increased levels of very-low density lipoprotein (VLDL) and intermediate-density lipoprotein (IDL), leading to elevated triglyceride levels. 22,23 We also found that in the PD group, patients have higher cholesterol and Apo-B levels than in HD group, as reported previously. 7,24,25 A possible explanation for this abnormality is the exposure of patients to glucose in the dialysate and insulin resistance that activates the delivery of free fatty acids (FFAs) to the liver and subsequently the oxidation or esterification of FFAs to cytosolic triglycerides or VLDL.…”

Association of serum fetuin A with truncal obesity and dyslipidemia in non-diabetic hemodialysis patients

“…This may partially explain why the association between fetuin A and dyslipidemia occurs mainly on the non-HDL-C and TG components. On the relationship between dyslipidemia and CV mortality (29)(30)(31), the relationship between high fetuin A and CV mortality warrants further investigation through larger studies because its reverse impact on CV mortality related to malnutrition and CV calcification in dialysis patients has been shown in previous studies (3,18).…”

Therapeutic Management in Patients with Renal Failure who Experience an Acute Coronary Syndrome

“…Furthermore, fibrates can cause a hemodynamic decrease in GFR (29) and are used with caution in patients with CKD. Physicians may also be more reluctant to prescribe lipid-lowering agents to a patient population in whom a clear benefit from these drugs has never been shown (30,31) and who often have polypharmacy, increasing the risk of drug interactions and side effects (32,33). Although many reasons can explain the differences we observed, physicians should keep in mind that subgroup analyses from randomized controlled trials clearly show a beneficial effect of statins in the prevention of future cardiovascular events in subjects with moderate kidney dysfunction (34,35).…”