Dyslipidaemia in patients with chronic kidney disease – a neglected cardiovascular risk factor
Keywords:chronic kidney disease, Dyslipidaemia, cardiovascular disease, South Africa
Background. Atherosclerotic cardiovascular disease (ASCVD) is a major cause of morbidity and mortality in patients with chronic kidney disease (CKD). In addition, CKD itself is a coronary artery disease equivalent due to its atherogenic potential. Despite the role of CKD in ASCVD and recommendations to control lipid levels aggressively, landmark lipid studies have often excluded patients with advanced CKD. Furthermore, there is a scarcity of data on the use and efficacy of lipid-lowering therapy (LLT) in those with CKD in South Africa (SA). Objectives. To determine the prevalence and control of dyslipidaemia in a cohort of SA patients with CKD.
Methods. A retrospective, cross-sectional observational study of 250 patients with CKD attending the Charlotte Maxeke Johannesburg Academic Hospital renal clinic from 1 July 2019 to 31 July 2020 was carried out. Lipograms, the use of LLT and achievement of target lipid levels were examined.
Results. The median (interquartile range) age of this cohort was 58 (46 - 69) years; 50.4% were males and 64.4% black African. Dyslipidaemia was prevalent in 83.6% (n=209) of patients. A total of 169 (67.6%) patients were on LLT, and of these only 28 (16.6%) achieved the recommended low-density lipoprotein cholesterol (LDL-C) target. Of those not on LLT, 51 (63%) were eligible for LLT and almost all were classified as either very high risk (64.2%) or high risk (28.4%) for ASCVD. Of those on LLT, all were on statin therapy, of which simvastatin at a mean dose of 20 mg daily was the most commonly prescribed LLT.
Conclusion. This cohort comprised a large proportion of patients classified as high or very high risk for ASCVD. Despite this, the use of LLT was inadequate, and <20% of patients were at target LDL-C levels. These data suggest a greater need for awareness of initiating LLT to achieve recommended target LDL-C levels in patients with CKD.
. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/ APhA/ASPC/NLA/PCNA Guideline on the management of blood cholesterol. J Am Coll Cardiol 2019;73(24):e285-350. https://doi.org/10.1016/j.jacc.2018.11.003
World Health Organization. Cardiovascular diseases (CVDs). Geneva: WHO, 2021. https://www.who. int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds) (accessed 31 August 2021).
Byrne J, Eksteen G, Crickmore C. Heart and stroke foundation South Africa cardiovascular disease statistics reference document. Vlaeberg: Heart and Stroke Foundation South Africa, 2016. http://www. heartfoundation.co.za/wp-content/uploads/2017/10/CVD-Stats-Reference-Document-2016-FOR- MEDIA-1.pdf (accessed 1 December 2019).
Reiger S, Jardim TV, Abrahams-Gessel S, et al. Awareness, treatment, and control of dyslipidemia in rural South Africa: The HAALSI (Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa) study. PLoS ONE 2017;12(10):e0187347. https://doi.org/10.1371/journal. pone.0187347
Raal FJ, Blom DJ, Naidoo S, Bramlage P, Brudi P. Prevalence of dyslipidaemia in statin-treated patients in South Africa: Results of the DYSlipidaemia International Study (DYSIS). Cardiovasc J Afr 2013;24(8):330-338. https://doi.org/10.5830/cvja-2013-071
Ntusi N. Dyslipidaemia in South Africa. S Afr Med J 2018;108(4):256-257. https://doi.org/10.7196/ SAMJ.2018.v108i4.13265
Obialo CI, Ofili EO, Norris KC. Statins and cardiovascular disease outcomes in chronic kidney disease: Reaffirmation vs. repudiation. Int J Environ Res Public Health 2018;15(12):2733. https://doi. org/10.3390/ijerph15122733
Jungers P, Massy ZA, Nguyen Khoa T, et al. Incidence and risk factors of atherosclerotic cardiovascular accidents in predialysis chronic renal failure patients: A prospective study. Nephrol Dial Transplant 1997;12(12):2597-2602. https://doi.org/10.1093/ndt/12.12.2597
Kundhal K, Lok CE. Clinical epidemiology of cardiovascular disease in chronic kidney disease. Nephron Clin Pract 2005;101(2):c47-c52. https://doi.org/10.1159/000086221
Klug EQ, Raal FJ. New cholesterol targets for patients at high or very high cardiovascular risk and the indications for PCSK9 inhibitors. S Afr Med J 2020;110(11):1059. https://doi.org/10.7196/SAMJ.2020. v110i11.15191
Mach F, Baigent C, Catapano AL, et al. 2019 ESC/EAS guidelines for the management of dyslipidaemias: Lipid modification to reduce cardiovascular risk: The task force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS). Eur Heart J 2019;41(1):111-188. https://doi.org/10.1093/eurheartj/ehz455
Kovell L. Lipid management guidelines for adults with chronic kidney disease. Washington: American College of Cardiology, 2016. https://www.acc.org/latest-in-cardiology/articles/2016/05/31/13/00/ lipid-management-guidelines-for-adults-with-chronic-kidney-disease (accessed 1 December 2019).
Kennard A, Singer R. Lipid lowering in renal disease. Aust Prescr 2017;40(4):141-146. https://doi. org/10.18773/austprescr.2017.047
Kuznik A, Mardekian J, Tarasenko L. Evaluation of cardiovascular disease burden and therapeutic goal attainment in US adults with chronic kidney disease: An analysis of national health and nutritional examination survey data, 2001 - 2010. BMC Nephrol 2013;14:132-142. https://doi.org/10.1186/1471- 2369-14-132
Madala ND, Thusi GP, Assounga AGH, Naicker S. Characteristics of South African patients presenting with kidney disease in rural KwaZulu-Natal: A cross sectional study. BMC Nephrol 2014;15(1):61-69. https://doi.org/10.1186/1471-2369-15-61
Voskamp PWM, van Diepen M, Dekker FW, Hoogeveen EK. Dyslipidemia and risk of renal replacement therapy or death in incident pre-dialysis patients. Sci Rep 2018;8(1):3130-3138. https:// doi.org/10.1038/s41598-018-20907-y
Wong MG, Wanner C, Knight J, Perkovic V. Lowering cholesterol in chronic kidney disease: Is it safe and effective? Eur Heart J 2015;36(43):2988-2995. https://doi.org/10.1093/eurheartj/ehv393
Newman CB, Preiss D, Tobert JA, et al. Statin safety and associated adverse events: A scientific statement from the American Heart Association. Arterioscler Thromb Vasc Biol 2019;39(2):e38-e81. https://doi.org/10.1161/atv.0000000000000073
Herselman M. Non-adherence to dietary prescriptions in chronic kidney disease. South Afr J Clin Nutr 2008;21(2):13-14. https://doi.org/10.1080/16070658.2008.11734156
Lansberg P, Lee A, Lee ZV, Subramaniam K, Setia S. Nonadherence to statins: Individualised intervention strategies outside the pill box. Vasc Health Risk Manag 2018;2018(14):91-102. https:// doi.org/10.2147/vhrm.s158641
Copyright (c) 2023 M R Essop, F Seedat, F J Raal
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
The SAMJ is published under an Attribution-Non Commercial International Creative Commons Attribution (CC-BY-NC 4.0) License. Under this license, authors agree to make articles available to users, without permission or fees, for any lawful, non-commercial purpose. Users may read, copy, or re-use published content as long as the author and original place of publication are properly cited.
Exceptions to this license model is allowed for UKRI and research funded by organisations requiring that research be published open-access without embargo, under a CC-BY licence. As per the journals archiving policy, authors are permitted to self-archive the author-accepted manuscript (AAM) in a repository.
Authors grant the Publisher the exclusive right to publish, display, reproduce and/or distribute the Work in print and electronic format and in any medium known or hereafter developed, including for commercial use. The Author also agrees that the Publisher may retain in print or electronic format more than one copy of the Work for the purpose of preservation, security and back-up.