How to manage high cholesterol and kidney disease
Written by:In people with chronic kidney disease (CKD) heart disease is very common and it is therefore recommended that those with CKD should have their cholesterol tested every year.
We’ve asked consultant nephrologist Dr Christopher Lawrence to explain what risk factors increase the chance of developing high cholesterol and how these can be managed as a preventative for renal disease.
What advice would you give to someone with high cholesterol?
In the setting of renal disease, any advice is, by definition, not particularly well supported by evidence but is instead driven by practical approaches, experience and common sense. In these situations, the advice I give patients is what I would follow myself if in the same position. Before addressing high cholesterol I would make sure that I had addressed all of my other risk factors.
What are the risk factors?
Smoking is particularly hazardous to vascular health amongst other recreational hazards. Diabetes must be brought under control. Excess weight should be addressed by following a low carbohydrate diet. Prioritisation of cholesterol over all other risk factors has led to a low-fat diet being advised in many countries around the world. One major problem with a low-fat diet is that they tend to be high in carbohydrates which results in excess weight gain, a preponderance to diabetes and consequently vascular complications!
After addressing risk factors, what else can I do?
Once non-smoking, cured of diabetes (or prevented from becoming diabetic, or under excellent diabetic control), lean (or at least on the path to being lean) then I would consider my risk of cardiovascular disease from a personal perspective.
If I had no family history of vascular disease, mild kidney impairment, no albuminuria and no other risk factors for vascular disease, I would then assess my cholesterol. I would take into account my total cholesterol:HDL ratio. If my LDL cholesterol were over three and I had an adverse total cholesterol:HDL ratio then I would consider taking a statin. It’s important to be aware that the ‘numbers needed to treat’ (that is the number of people in my position who would need to take a statin before one person benefitted) would be quite high.
Conversely, if I had multiple risk factors for vascular disease, had moderate to severe kidney impairment with moderate or worse albuminuria, then I might be tempted to take a statin no matter what my cholesterol reading was. I would certainly have a lower threshold for starting a statin and would consider treatment if my LDL cholesterol was more than 2 or if I had a poor Total cholesterol:HDL ratio.
Is aspirin beneficial for treating cardiovascular disease?
The evidence for other preventative measures like aspirin is disproven for primary prevention in the general population. Aspirin can cause an equal amount of harm as good in people who have not had a heart attack. If, however, I had particularly strong risk factors for vascular disease then I might be tempted also to take an aspirin (75 (UK) or 81 (USA) mg daily), with of course a small dose of ranitidine (75mg daily, to protect my stomach lining from the effects of aspirin).
How long should I take statins for?
Statins are not entirely without complications or side effects, although I feel the downsides of statins are somewhat overstated. As the benefits of taking statins accrue with time, it may be that there is an optimal age range during which to take them. I would be more permissible of a higher cholesterol level in elderly people as they are more prone to certain statin-related side effects like memory loss and falls.
It is probably not advisable to stop taking statins suddenly once on them for a period of time, this is because of the risk of destabilising cholesterol plaques. However, if experiencing side effects, then it may be worth considering reducing the dose or trying a different variety, rather than just stopping.
