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K/DOQI Gets to the Heart of Managing Dyslipidemias in Patients with CKD
| The Issues in Renal Nutrition
in Nephrology Nursing department is designed to focus on nutritional
issues for nephrology patients. Address correspondence to: Deborah Brommage,
Department Editor, Nephrology Nursing Journal; East Holly Avenue/Box
56; Pitman NJ 08071-0056; (856) 256-2320. The opinions and assertions
contained herein are the private views of the contributors and do not
necessarily reflect the views of the American Nephrology Nurses'
Association. |
Patients with chronic kidney disease (CKD) are at a higher risk for
cardiovascular disease (CVD) than patients in the general population.
Lipid abnormalities may contribute to the cardiovascular burden in
patients with CKD. As a result, the National Kidney Foundation (NKF)
Kidney Disease Outcome Quality Initiative (K/DOQI) convened a work
group to develop guidelines for the assessment and treatment of
dyslipidemias in patients with CKD, irregardless of the underlying
cause of the kidney disease. The work group developed 5 dyslipidemia
guidelines each with background information, rationale supported by
evidence, discussion of clinical application, implementation and
research recommendations. Understanding these guidelines may enhance
the health care team’s ability to implement treatment strategies
designed to reduce risk and improve patient outcomes.
Guidelines 1 – 5: An Overview
Guideline 1
addresses assessment of dsylipidemia in patients with CKD. The first
guideline recommends all adults and adolescents with CKD be evaluated
for dyslipidemias The assessment should include a complete fasting
lipid profile with total cholesterol, LDL, HDL, and triglycerides. The
guideline makes specific recommendations for adults and adolescents
with Stage 5 CKD, stating these patients should be evaluated for
dyslipidemias upon presentation (when the patient is stable), at 2-3
months after a change in treatment or other conditions known to cause
dyslipidemias; and at least annually thereafter.
Guideline 2
addresses measurement of lipid profiles and recommends fasting lipid
profiles in Stage 5 CKD. The recommendation is to obtain a complete
lipid profile measured after an overnight fast whenever possible. The
guideline discussion acknowledges fasting lipid profiles are best, yet
states it is better to obtain non-fasting lipid profiles than to forgo
evaluation. In the chronic dialysis setting, the time the patient is on
dialysis may affect the practical aspects of obtaining a fasting draw.
There is some evidence to suggest the dialysis procedure may alter
lipid profiles therefore the guideline suggests patients on
hemodialysis should have lipid profiles measured either before
dialysis, or on days not receiving dialysis. For patients on peritoneal
dialysis the background information suggests to draw blood in the
morning after an overnight fast (whenever possible), and with whatever
peritoneal dialysis fluid is dwelling in the peritoneal cavity.
Guideline 3
discusses secondary causes and recommends Stage 5 patients with CKD
with dyslipidemias be evaluated by the health care team for secondary
causes such as nephrotic syndrome, hypothyroidism, diabetes, excess
alcohol consumption and liver disease. In addition medications should
be evaluated for any potential secondary causes.
Guideline 4
reviews the general approach to treating dyslipidemia in adults with
CKD and closely follows the approach adopted by the ATP III guidelines.
The guideline recommends therapeutic lifestyle changes (TLC) and
consideration of a triglyceride-lowering agent for adults with Stage 5
CKD with fasting triglycerides > 500 mg/dL that cannot be corrected
by removing an underlying cause. In addition guideline 4 recommends
treatment be considered to reduce LDL to < 100 mg/dL for adults with
Stage 5 CKD with LDL > 100mg/dL. Another recommendation is to
consider treatment to reduce non-HDL cholesterol to <130 mg/dL for
adults with Stage 5 CKD with LDL <100 mg/dL, fasting triglycerides
> 200 mg/dL, and non-HDL cholesterol (total cholesterol minus HDL)
> 130 mg/dL.
Guideline 5
focuses on treatment of lipid abnormalities in adolescents with Stage5
CKD. The guideline recommends considering therapeutic lifestyle changes
(TLC) for adolescents with Stage 5 CKD with fasting triglycerides >
500 mg/dL that cannot be corrected by removing an underlying cause.
Another concern is that treatment be considered to reduce LDL to <
130 mg/dL for adolescents with Stage 5 CKD and LDL > 130 mg/dL. In
addition, treatment should be considered to reduce non-HDL cholesterol
to <160 mg/dL for adolescents with Stage 5 CKD and LDL <130
mg/dL, fasting triglycerides > 200 mg/dL, and non-HDL cholesterol
(total cholesterol minus HDL) > 160 mg/dL.
Diet and Therapeutic Lifestyle Changes
Although
diet and therapeutic lifestyle changes were not included as specific
guidelines, there is a great deal of background information and
specific recommendations provided in the appendixes of the guidelines.
Appendix 2, for example, states comprehensive nutrition counseling
should be offered to all patients with CKD by an experienced dietitian.
During the initial assessment and subsequent follow-up of patients with
CKD, it is always important to assess malnutrition. If the patient is
well nourished, dietary modifications for dyslipidemias can be
undertaken safely (NKF, 2003). Table 2 summarizes the primary diet and
therapeutic lifestyle recommendations. In the background discussion we
are reminded of the importance to consider patients with low total
cholesterol as potential candidates for malnutrition. The recommended
diet and therapeutic lifestyle changes are consistent with
recommendations for the general population and are considered safe to
implement with patients with CKD as long as their nutritional status is
monitored.
Summary
There
is a wealth of data in the general population regarding interventions
to reduce cardiovascular risk. Unfortunately, most of these studies
exclude patients with chronic kidney disease. As a result, the lack of
CKD specific data has resulted in a lack of attention and intervention.
With the epidemic levels of cardiovascular disease in patients on
dialysis, the NKF has established these K/DOQI guidelines in an effort
to get to the “heart” of dyslipidemias and ultimately to assist the
health care team in their effort to improve CKD patient outcomes. In
addition, the National Kidney Foundation currently has draft K/DOQI
Clinical Practice Guidelines for Cardiovascular Disease in the
public review process. These new guidelines will elaborate on
areas not covered in the dyslipidemia guidelines.
References
National
Kidney Foundation. (2003). K/DOQI Clinical practice guidelines
for managing dyslipidemias in chronic kidney disease. American Journal
of Kidney Diseases, 41, S1-S92, 2003 (suppl 3) Also available at
www.kidney.org
Weiner, D., & Sarnak, M.J. (2004) Managing dyslipidemia in chronic kidney disease. Journal of Internal Medicine, 19, 1045.
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