Mortality and Cardiovascular Outcomes Associated with Statin Use in Dialysis Patients with Atherosclerotic Cardiovascular Disease: A Systematic Review and Meta-Analysis.

INTRODUCTION: Dialysis patients with established atherosclerotic cardiovascular disease (ASCVD) face exceptionally high risks of mortality and recurrent cardiovascular events, yet remain substantially underrepresented in major statin trials. We aimed to synthesize evidence from studies restricted to this population to evaluate the association between statin therapy and clinical outcomes. METHODS: We systematically searched Embase, MEDLINE, Web of Science, Scopus, and CENTRAL databases from inception through February 20, 2025, for randomized controlled trials and observational studies evaluating statin therapy in adults receiving maintenance dialysis with documented ASCVD. Hazard ratios were pooled using random-effects models. Risk of bias was assessed using the ROBINS-I tool. The primary outcome was all-cause mortality. RESULTS: Fourteen cohort studies comprising 242,118 patients were included in the meta-analysis. Statin therapy was associated with a significant reduction in all-cause mortality (HR 0.85, 95% CI 0.74-0.98; P = 0.027; I² = 53.1%). Associations with cardiac mortality (HR 0.88, 95% CI 0.66-1.16; I² = 79.6%) and major adverse cardiovascular events (HR 0.85, 95% CI 0.59-1.21; I² = 61.8%) were not statistically significant. Leave-one-out sensitivity analyses supported the robustness of the primary finding. Among dialysis patients with established ASCVD, the proportion of statin-treated patients was 35% and increased over time. CONCLUSIONS: Among dialysis patients with established ASCVD, statin therapy is associated with lower all-cause mortality; however, its effect on cardiovascular outcomes remains uncertain. Substantial heterogeneity and a predominance of observational evidence limit causal inference. Well-designed prospective trials in this high-risk population are warranted.