Chapter 1: Assessment of lipid status in adults with CKD

RATIONALE Dyslipidemia is common but not universal in people with CKD. The major determinants of dyslipidemia in CKD patients are glomerular filtration rate (GFR), the presence of diabetes mellitus, severity of proteinuria, use of immunosuppressive agents, modality of renal replacement therapy [RRT] (treatment by HD, peritoneal dialysis, or transplantation), comorbidity and nutritional status. Initial evaluation of the lipid profile mainly serves to establish the diagnosis of severe hypercholesterolemia and/or hypertriglyceridemia and potentially rule out a remediable (secondary) cause if present. Major causes of secondary dyslipidemia should be considered (Table 1). The precise levels of serum or plasma lipids that should trigger specialist referral are not supported by evidence, but in the opinion of the Work Group, fasting triglyceride (TG) levels above 11.3 mmol/l (1000 mg/dl) or LDL-C levels above 4.9 mmol/l (190 mg/dl) should prompt consideration of (or specialist referral for) further evaluation. Previous guidelines have emphasized the potential value of LDL-C as an indication for pharmacological treatment with lipid-lowering agents; the KDIGO Work Group no longer recommends this approach (see Chapter 2.1). Isolated low high-density lipoprotein cholesterol (HDL-C) does not imply specific therapy in people with CKD; the Work Group suggests that HDL-C be measured as part of the initial lipid panel because it may help to assess overall cardiovascular risk. Measurement of lipoprotein(a) [Lp(a)] and other markers of dyslipidemia require further research before it can be routinely recommended in CKD patients. The lipid profile should ideally be measured in the fasting state; if not feasible, nonfasting values provide useful information as well. Fasting will mainly affect TG values and to a lesser extent LDL-C values as estimated from the Friedewald formula. Fasting status does not affect HDL-C. There is no direct evidence indicating that measurement of lipid status will improve clinical outcomes. However, such measurement is minimally invasive, relatively inexpensive, and has potential to improve the health of people with secondary dyslipidemia. In the judgment of the Work Group, patients with CKD place a high value on this potential benefit and are less concerned about the possibility of adverse events or inconvenience associated with baseline measurement of lipid levels. In the judgment of the Work Group, these considerations justify a strong recommendation despite the low quality of the available evidence.