Molitch Mark E
Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, 303 E. Chicago Avenue (Tarry 15-731), Chicago, IL 60611, USA.
Clin J Am Soc Nephrol. 2006 Sep;1(5):1090-9. doi: 10.2215/CJN.00780306. Epub 2006 Jul 26.
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.
心血管疾病（CVD）是5期慢性肾脏病（CKD）患者的主要死因，而糖尿病患者的5期CKD死亡率更高。降低CVD风险包括控制高血糖、血脂异常和血压。对于此类高危患者，建议将低密度脂蛋白胆固醇目标设定为70mg/dl。大多数显示他汀类药物可降低CVD风险的研究针对的是无CKD的患者。然而，一些研究纳入了足够数量的2至3期CKD患者以进行分析，这些研究总体上显示出与无CKD患者相似的CVD获益。显示对透析患者或移植后患者有益的研究结果不一，部分原因是此类患者的CVD已相当严重，可能对干预的反应不佳。随着肾小球滤过率（GFR）下降，许多用于治疗血脂异常药物的剂量需要调整。然而，一般来说，阿托伐他汀和氟伐他汀的剂量无需调整。与环孢素也会发生药物相互作用。一般应避免他汀类药物与贝特类药物联用，GFR水平降低的所有患者均应避免使用非诺贝特。总体而言，鉴于糖尿病和CKD患者发生CVD的风险非常高，有必要积极管理血脂异常，将低密度脂蛋白目标设定为70mg/dl。
