Blog entry by Meguid El Nahas
The swedish SWEDEHEART study group reported data from their nationwide registry on 42,814 consecutive survivors of myocardial infarction (MI). They noted that the prescription of statins on discharge from hospital after an MI improved survival rate at 1 year mainly in patients with CKD2-4. The effect in those with CKD5 was less obvious. This observation is at variance with those made in recent clinical trials on the use of statins in CKD patients. Statins have failed to improve survival in patients with CKD5 on dialysis; 4D and AURORA trials. However, the SHARP study group presented (ASN 2010) the results of their trial on the use of simvastatin and ezetemibe in patients with CKD3-5 (including some on RRT) and showed a reduction in overall major cardiovascular events. This effect was more noticeable in those with CKD3-4 compared to those on dialysis where the impact was less significant. However, SHARP failed also to show improved overall survival. This is at variance with the SWEDEHEART data. This follows a common pattern of positive reports of interventions in CKD patients based on observational studies that are not fully substantiated when tested in an RCT setting.
So...to use or not to use Statins in CKD? that is the question!
I would personally say use it in CKD patients with a history of IHD. Wait for a more detailed anlysis and publication of the SHARP study before you prescribe them prophylactically to reduce CV risk in pre-dialysis patients. Do not prescribe them for primary prophylaxis in those on dialysis (in agreement with published guidelines). Of note, these drugs are not without side effects and have been associated with increased cerebrovascular accidents/hemorrhages in a number of clinical trials, including those in HD patients; 4D and AURORA.