Management of dyslipidemias in patients with diabetes and chronic kidney disease.

Cardiovascular disease (CVD) is the leading cause of death in patients with stage 5 chronic kidney disease (CKD), and the mortality rate in stage 5 CKD is even higher in patients with diabetes. CVD risk reduction includes control of hyperglycemia, dyslipidemia, and BP. An LDL cholesterol goal of 70 mg/dl has been suggested for such high-risk patients. Most studies that have showed CVD risk reduction with statins have been in patients without CKD. However, some studies have had sufficient numbers of patients with CKD stages 2 to 3 to permit analysis, and these generally have shown CVD benefits similar to those found in patients without CKD. Studies that have shown benefit in patients who were on dialysis or after transplantation have been mixed, in part because CVD in such patients is far advanced and may not respond as well to intervention. As GFR falls, the dosages of many of the drugs that are used for the treatment of dyslipidemias need to be modified. In general, however, atorvastatin and fluvastatin dosages do not have to be modified. Drug interactions with cyclosporine also occur. In general, combinations of statins and fibrates should be avoided, and fenofibrate should be avoided in all patients with decreased GFR levels. Overall, on the basis of the very high risk for CVD in patients with diabetes and CKD, aggressive management of dyslipidemias is warranted, with an LDL goal of 70 mg/dl.