Evaluation of LDL-Cholesterol Target Attainment in CKD: A Real-World Audit Against European Society of Cardiology Guidelines

Background: Cardiovascular disease is the leading cause of mortality in chronic kidney disease (CKD). The European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS) classify CKD as a condition with high or very high cardiovascular risk, increasing with CKD stage. An LDL cholesterol (LDL-C) target of ≤1.4mmol/L is recommended for those with estimated glomerular filtration rate (eGFR) <30 mL/min/1.73m2 and ≤1.8mmol/L for those with eGFR 30–59 mL/min/1.73m2. This audit evaluates LDL-C target attainment and the frequency of lipid-lowering therapy (LLTx) prescribing in a single-centre CKD cohort. Methods: Medication and laboratory records for all patients with an eGFR <60mL/min/1.73m2, but not on dialysis, and kidney transplants who attended a single-centre nephrology outpatient clinic between December 2023 and December 2024 were retrospectively reviewed. Individuals were categorised by eGFR (stage 3 = eGFR 30–59mL/min/1.73m2; stage 4/5 = eGFR 1-29mL/min/1.73m2) and transplant status. LDL-C levels, LLTx use, and adherence to ESC targets were determined. Results: Of 608 individuals in the cohort, 47 were excluded (10 had hypertriglyceridaemia rendering LDL-C incalculable, 37 did not have lipids measured). Among non-transplant stage 4/5 CKD (n=299), only 29% (n=86) met the LDL-C target (≤1.4mmol/L) with 71% (n=213) off-target, with a mean LDL-C excess of 0.99mmol/L. Notably, 37% of those not at target (n=79) were not on any LLTx. Of those on maximum dose statin (n=25), 56% (n=14) remained off target. Among CKD stage 3 (n=180), only 11% (n=19) met the LDL-C target (<1.8mmol/L) with 89% (n=161) off-target, with a mean LDL-C excess of 2.39mmol/L. In the kidney transplant cohort, LDL-C target attainment was higher in those with stage 4 and 5 CKD (5/13; 38%) but remained suboptimal in those with stage 3 CKD (19/71; 27%). A substantial proportion of transplant recipients (42%) were not on any LLTx. Conclusion: LDL-C target attainment in our CKD and transplant cohort is suboptimal and not adherent to ESC recommendations. The majority of patients are untreated or inadequately treated, particularly those with stage 3 CKD. These findings underscore the need for enhanced lipid management strategies, including early intervention, combination therapy & multidisciplinary collaboration to improve cardiovascular outcomes in this high-risk population.