Why should pharmacologic therapy not be initiated in patients receiving chronic dialysis but be continued if patients are already taking statins?
The KDIGO guidelines recommend against initiating statins in dialysis patients. Two trials—4D (Die Deutsche Diabetes Dialyse) study, in which hemodialysis patients with diabetes and high serum LDL were treated with atorvastatin or placebo; and AURORA (Use of Rosuvastatin in subjects On Regular hemodialysis: an Assessment of survival and cardiovascular events), in which dialysis patients were treated with rosuvastatin or placebo—failed to demonstrate a significant reduction in mortality or other CVD outcomes.
The SHARP trial reported no interaction between dialysis and non-dialysis participants with regard to the simvastatin/ezetemibe benefit; however, an analysis limited to dialysis patients did not demonstrate a benefit.
In the SHARP trial, 34% of CKD stage 3 to 5 patients progressed to ESKD during the course of the trial, and because an overall benefit in the non-dialysis patients was reported, the KDIGO guidelines recommend that statins be continued at the time of dialysis initiation. Importantly, these guidelines in dialysis patients do not consider patients with recent acute coronary events, younger patients with longer life expectancies, and those who might receive a kidney transplant and therefore receive a yet unquantified benefit from the initiation of statin therapy.