Definitions for the levels of evidence (I–IV) can be found at the end of the "Major Recommendations" field.
Guidelines
No recommendations possible based on Level I or II evidence
Suggestions for Clinical Care
(Suggestions are based on Level III and IV evidence)
- All persons with chronic kidney disease (CKD) (pre-dialysis) should have regular checks of their serum cholesterol and triglycerides, and the blood cholesterol target should be similar to guidelines for the non-renal disease population. (Opinion)
- Cholesterol-lowering medication therapy should be commenced in patients with CKD (pre-dialysis) who have failed to attain a serum cholesterol below 4.5 mmol/L with dietary manipulation. The 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase inhibitors (statins) are the choice for low high density lipoprotein (HDL) and/or elevated low density lipoprotein (LDL). (Opinion)
The implementation of local guidelines (when available) for the vascular health of the non-renal failure population is recommended for the pre-dialysis renal patient. Care must be taken with the choice of therapies for reducing blood lipid levels.
In non-diabetic CKD patients, the hypertriglyceridaemia can be reduced by both increasing the dietary polyunsaturated: saturated fat ratio and by reducing the carbohydrate content of the diet. Dietary modification under the supervision of a suitably qualified dietician may be helpful for managing the hypertriglyceridaemia. Patients with other coronary risk factors (i.e., smoking, hypertension, obesity, and lack of exercise) should be encouraged to modify their behaviour, in conjunction with adopting the modified lipid diet.
If dietary intervention is inadequate, a fibrate to lower blood cholesterol levels should be considered. The dual benefit of triglyceride lowering and HDL elevation is achieved with this therapy. However, fibrates can lead to deterioration in the glomerular filtration rate (GFR). Regular monitoring of the serum creatinine, at least 3-monthly, during the fibrate therapy should be undertaken. The fibrate should be ceased if any persisting unexpected rise in the serum creatinine of more than 20% occurs. Consideration of further investigation before reintroduction of the fibrate should be given if the creatinine does not improve within 3 months of the patient being off the fibrate medication. The reduction in the GFR is usually reversible when this policy is practiced.
Definitions:
Levels of Evidence
Level I: Evidence obtained from a systematic review of all relevant randomized controlled trials (RCTs)
Level II: Evidence obtained from at least one properly designed RCT
Level III: Evidence obtained from well-designed pseudo-randomized controlled trials (alternate allocation or some other method); comparative studies with concurrent controls and allocation not randomized, cohort studies, case-control studies, interrupted time series with a control group; comparative studies with historical control, two or more single arm studies, interrupted time series without a parallel control group
Level IV: Evidence obtained from case series, either post-test or pretest/post-test
