Lipid-lowering for people with chronic kidney disease: a narrative review

Chronic kidney disease (CKD) affects approximately 14% of adults worldwide, and CKD independently contributes to cardiovascular risk. Hereby, we provide a narrative review of cholesterol-lowering therapies for people with CKD. Abnormal levels of cholesterol and triglycerides are common in CKD and contribute to cardiovascular risk beyond common risk factors like older age, hypertension and diabetes, although the role of cholesterol and triglycerides in kidney disease progression remains uncertain. 3-hydroxy-3-methylglutaryl-coenzyme A (HMG CoA) reductase inhibitors (statins), alone or combined with ezetimibe, are the most extensively studied treatment in reducing cholesterol and lipids in CKD. Large randomised controlled trials (RCTs) and meta-analyses show statins reduce cardiovascular events and death in CKD, but not in people requiring dialysis despite similar cholesterol-lowering effects. Statins may also improve kidney function but have not demonstrated a benefit in reducing kidney failure. Current clinical guidelines recommend statins, with or without ezetimibe, for most adults with CKD, with therapy individualised based on age, kidney function and cardiovascular risk. However, guidelines in CKD do not indicate any cholesterol targets to guide escalation of treatments. Newer therapies, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors and small interfering RNA (eg, inclisiran) demonstrated cardiovascular benefit in the general population, but evidence in CKD is limited. Further research on these therapies is needed to define their role in improving cardiovascular and kidney outcomes in people with CKD.