Rupert W. Major

Statins and Cardiovascular Primary Prevention in CKD: A Meta-Analysis

BACKGROUND AND OBJECTIVES Multiple meta-analyses of lipid-lowering therapies for cardiovascular primary prevention in the general population have been performed. Other meta-analyses of lipid-lowering therapies in CKD have also been performed, but not for primary prevention. This meta-analysis assesses lipid-lowering therapies for cardiovascular primary prevention in CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A systematic review and meta-analysis using a random-effects model was performed. MEDLINE was searched between January 2012 and September 2013 for new studies using predefined search criteria without language restrictions. A number of other sources including previously published meta-analyses were also reviewed. Inclusion criteria were randomized control trials of primary prevention with lipid-lowering therapy in non-end stage CKD. RESULTS Six trials were identified, five including patients with stage 3 CKD only. These studies included 8834 participants and 32,846 person-years of follow-up. All trials were post hoc subgroup analyses of statins in the general population. Statins reduced the risk of cardiovascular disease (the prespecified primary outcome) by 41% in stages 1-3 CKD compared with placebo (pooled risk ratio, 0.59; 95% confidence interval [95% CI], 0.48 to 0.72). For the secondary outcomes, the risk ratios were 0.66 (95% CI, 0.49 to 0.88) for total mortality, 0.55 (95% CI, 0.42 to 0.72) for coronary heart disease events, and 0.56 (95% CI, 0.28 to 1.13) for stroke. In study participants with stage 3 CKD specifically, the results were similar. CONCLUSIONS This meta-analysis suggests that the use of statins in CKD for primary prevention of cardiovascular disease is effective. These findings are consistent with recent guidance for the use of statins in all patients with CKD.

Association between undiagnosed hypertension and microalbuminuria in South Asians without known diabetes

Data suggest increased rates of chronic kidney disease (CKD) in those with undiagnosed hypertension (HTN). Our study aimed to determine the prevalence of CKD in undiagnosed hypertensives in a previously unreported subgroup of individuals of South Asian ethnicity. We analysed data from subjects in the ADDITION-Leicester study, a UK based multiethnic, community diabetes screening study. Standard definitions included: HTN—mean recorded BP of ⩾140/90 mm Hg, CKD stage 3 and above—estimated glomerular filtration rate (eGFR) <60 ml min−1 per 1.73 m2 and microalbuminuria as albumin creatinine ratio ⩾3 mg mmol−1. Logistic regression was performed with age, gender and body mass index (kg m−2) as co-variates. 6082 individuals (52.5% female, mean age, 57.2 years; White European, 77.8% and South Asian, 22.0%), 31.1% had undiagnosed HTN. Overall, individuals with undiagnosed HTN compared with normotensives had an odds ratio for microalbuminuria of 2.24 (95% confidence interval (CI): 1.72–2.94). For South Asians, the odds ratio was 3.81. (95% CI: 2.24–6.47) for microalbuminuria with a trend towards an eGFR<60 ml min−1 per 1.73 m2. Future studies should consider intensified screening for HTN to refine the population suitable for CKD screening, particularly in the South Asian ethnic group.

Reclassification of Chronic Kidney Disease Stage, Eligibility for Cystatin-C and Its Associated Costs in a UK Primary Care Cohort.

Background and Aims: Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) estimations of glomerular filtration rate (eGFR), compared to modification of diet in renal disease (MDRD), have superior performance in predicting renal, cardiovascular and mortality events. Cystatin-C further improves prediction. Our primary aim was to assess the change in prevalence and classification of CKD in converting from MDRD to CKD-EPI in an unselected primary care CKD population. Our secondary aims were to determine the eligibility for cystatin-C testing based on National Institute for Health and Care Excellence guidance and the associated costs. Methods: eGFR data from an unselected UK primary care CKD cohort was studied to assess reclassification of CKD stages from MDRD to CKD-EPI, suitability for cystatin-C testing and its associated cost. Results: A total number of 24,660 individuals had ≥2 MDRD eGFR results <60 mL/min/1.73 m2 >3 months apart (7.0% of adult population). The mean age was 75.2 (SD 11.4 years) with 15,265 (61.9%) females. Mean eGFR was 2.88 mL/min/1.73 m2 lower with CKD-EPI eGFR versus MDRD eGFR (49.7 vs. 46.8, t test p < 0.0001, 95% CI 2.85–2.91). 12.0% of individuals were re-categorised to a more or less advanced CKD stage, and 1.3% to a less advanced stage. The percentage of the population categorised as 3a-A1 CKD-EPI and therefore potentially suitable for cystatin-C was 2.8%. The estimated initial cost is €67.5 (£57.2) million with annual costs of €2.7 (£2.3) million for the United Kingdom. Conclusions: The mean eGFR was lower with the CKD-EPI formula and individuals were more likely to be reclassified to more advanced CKD. This may be related to the higher mean age of this unselected population compared to previous studies. Refinements of eGFR formulae, CKD definitions and cystatin-C eligibility in unselected populations are required.

TO020ASSESSMENT AND MANAGEMENT OF RISK FACTORS IN PEOPLE WITH CHRONIC KIDNEY DISEASE AND DIABETES MELLITUS MULTIMORBIDITY

Chronic kidney disease (CKD) and diabetes mellitus (DM) are important risk factors for cardiovascular (CV) disease and are associated with increased CV events. Multimorbidity with both DM and CKD is increasing in prevalence. Appropriate monitoring and use of reninangiotensin system antagonists, as well as optimising blood pressure and lipid levels, are important strategies in the management of people with CKD. Whether the presence or absence of DM influences the clinical assessment of CKD is unknown. We aimed to establish rates of other comorbidities and commonly used medication prescription rates. We also aimed to establish if DM affected the likelihood of confirmatory eGFR or urinary protein assessment being performed.

Bodybuilding, exogenous testosterone use and myocardial infarction

### Learning Point for Clinicians Myocardial infarction in the young can be related to cocaine and anabolic steroid use. This case reminds us that although an uncommon cause, anabolic steroids should not be forgotten. Furthermore, this case teaches us the utility of repeating the clinical history, particularly when a ‘diagnostic dead end’ is reached or there is high clinical suspicion of something a patient may be reluctant to disclose. A 30-year-old male, presented with chest pain at rest. His electrocardiogram …

Lipid management: maximising reduction of cardiac risk

Editor – We enjoyed reading Webb et al ’s succinct review of lipid management (Clin Med December 2013 pp 619–20) in relation to cardiac risk. The authors are right that chronic kidney disease (CKD) increases the risk profi le of patients and affects lipid-lowering treatment thresholds. They also note that cardiac risk calculations are of limited value in CKD due to either a lower proportion of patients with CKD in the development and validation cohorts (QRisk: 0.15% of derivation cohort had CKD).1 or due to patient not being validated in CKD (Framingham).2 A cardiac risk score specifi cally for patients with CKD is therefore needed to improve risk stratifi cation. Until such a score is developed, perhaps we should consider, in line with the recent Kidney Disease Outcomes Quality Initiative update of dyslipidaemia management in CKD,3 universal use of statins in all patients with CKD aged over 50 years. ■