Harper Charles R, Jacobson Terry A
Department of Medicine, Emory University, Atlanta, Georgia 30303, USA.
J Am Coll Cardiol. 2008 Jun 24;51(25):2375-84. doi: 10.1016/j.jacc.2008.03.025.
The incidence of chronic kidney disease (CKD) in the U.S. continues to increase, and now over 10% of the U.S. population has some form of CKD. Although some patients with CKD will ultimately develop renal failure, most patients with CKD will die of cardiovascular disease before dialysis becomes necessary. Patients with CKD have major proatherogenic lipid abnormalities that are treatable with readily available therapies. The severe derangements seen in lipoprotein metabolism in patients with CKD typically results in high triglycerides and low high-density lipoprotein (HDL) cholesterol. Because of the prevalence of triglyceride disorders in patients with CKD, after treating patients to a low-density lipoprotein goal, non-HDL should be calculated and used as the secondary goal of treatment. A review of the evidence from subgroup analysis of several landmark lipid-lowering trials supports treating dyslipidemia in mild to moderate CKD patients with HMG-CoA reductase inhibitors. The evidence to support treating dyslipidemia in hemodialysis patients, however, has been mixed, with several outcome trials pending. Patients with CKD frequently have mixed dyslipidemia and often require treatment with multiple lipid-lowering drugs. Although statins are the cornerstone of therapy for most patients with CKD, differences in their pharmacokinetic properties give some statins a safety advantage in patients with advanced CKD. Although most other lipid-lowering agents can be used safely with statins in combination therapy in patients with CKD, the fibrates are renally metabolized and require both adjustments in dose and very careful monitoring due to the increased risk of rhabdomyolysis. After reviewing the safety and dose alterations required in managing dyslipidemia in patients with CKD, a practical treatment algorithm is proposed.
美国慢性肾脏病（CKD）的发病率持续上升，目前超过10%的美国人口患有某种形式的CKD。尽管一些CKD患者最终会发展为肾衰竭，但大多数CKD患者在需要透析之前会死于心血管疾病。CKD患者存在主要的促动脉粥样硬化性血脂异常，这些异常可用现有的疗法进行治疗。CKD患者脂蛋白代谢中出现的严重紊乱通常导致甘油三酯升高和高密度脂蛋白（HDL）胆固醇降低。由于CKD患者中甘油三酯紊乱普遍存在，在将患者治疗至低密度脂蛋白目标后，应计算非HDL并将其用作治疗的次要目标。对几项具有里程碑意义的降脂试验亚组分析的证据进行回顾，支持使用HMG-CoA还原酶抑制剂治疗轻度至中度CKD患者的血脂异常。然而，支持治疗血液透析患者血脂异常的证据并不一致，有几项结果试验正在进行中。CKD患者经常存在混合性血脂异常，通常需要使用多种降脂药物进行治疗。尽管他汀类药物是大多数CKD患者治疗的基石，但它们的药代动力学特性差异使一些他汀类药物在晚期CKD患者中具有安全优势。尽管大多数其他降脂药物可与他汀类药物在CKD患者联合治疗中安全使用，但贝特类药物经肾脏代谢，由于横纹肌溶解风险增加，需要调整剂量并进行非常仔细的监测。在回顾了管理CKD患者血脂异常所需的安全性和剂量调整后，提出了一种实用的治疗算法。
