Heine Gunnar H, Rogacev Kyrill S, Weingärtner Oliver, Marsche Gunther
Saarland University Medical Center, Homburg, Germany.
University Heart Center Luebeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein, Luebeck, Germany.
Semin Dial. 2017 Sep;30(5):390-394. doi: 10.1111/sdi.12621. Epub 2017 Jun 19.
Chronic kidney disease (CKD) patients have a high burden of cardiovascular disease. In the general population, lipid metabolism disorders, which cause the initiation and progression of atherosclerotic vascular changes, are major targets for preventive and therapeutic strategies in cardiovascular medicine. However, data from large cohort studies and from clinical trials suggest that the treatment guidelines on cardiovascular disease prevention and therapy cannot uncritically be transferred from individuals with intact renal function to CKD patients. Thus, unlike in the general population, neither plasma levels of HDL-cholesterol, nor the key parameter of HDL-cholesterol function-that is, cholesterol efflux capacity-predicts future cardiovascular events. Therefore, HDL-cholesterol should presently not be considered as therapeutic target in CKD patients. In contrast, lowering of LDL-cholesterol has been shown to reduce cardiovascular events at least among nondialysis CKD patients. The cardiovascular benefit of targeting LDL-cholesterol among dialysis CKD patients is less evident. We strongly believe that at least some subgroups of dialysis patients may profit from such treatment, particularly those with highest baseline LDL-cholesterol. Finally, as CKD patients have been characterized to have rather high intestinal cholesterol absorption, and relatively low hepatic cholesterol synthesis, substituting combined statin/ezetimibe treatment for statin monotherapy may be of particular benefit for nephrologic patients.
慢性肾脏病（CKD）患者心血管疾病负担较重。在普通人群中，导致动脉粥样硬化性血管病变发生和发展的脂质代谢紊乱是心血管医学预防和治疗策略的主要靶点。然而，大型队列研究和临床试验的数据表明，心血管疾病预防和治疗的指南不能不加批判地从肾功能正常的个体直接应用于CKD患者。因此，与普通人群不同，高密度脂蛋白胆固醇（HDL-胆固醇）的血浆水平以及HDL-胆固醇功能的关键参数——即胆固醇流出能力——均不能预测CKD患者未来的心血管事件。所以，目前不应将HDL-胆固醇视为CKD患者的治疗靶点。相比之下，降低低密度脂蛋白胆固醇（LDL-胆固醇）已被证明至少在非透析CKD患者中可减少心血管事件。在透析CKD患者中，以LDL-胆固醇为治疗靶点的心血管获益不太明显。我们坚信，至少部分透析患者亚组可能会从这种治疗中获益，尤其是那些基线LDL-胆固醇水平最高的患者。最后，由于CKD患者的肠道胆固醇吸收较高，而肝脏胆固醇合成相对较低，用他汀类药物/依折麦布联合治疗替代他汀类药物单药治疗可能对肾病患者特别有益。
