Quality statement 3: Statins for people with CKD
Adults with chronic kidney disease (CKD) are offered atorvastatin 20 mg. [new 2017]
There is a higher risk of cardiovascular disease (CVD) in people with CKD. After discussing the risks and benefits of starting statin therapy with a healthcare professional, adults with CKD may choose statin therapy as an appropriate treatment to reduce their risk of first CVD events, or of future CVD events in adults who have already had an event, such as a heart attack or stroke. Statins are a clinically effective treatment for preventing CVD, and reducing the risks associated with CVD, for people who have CKD. Atorvastatin 20 mg is recommended as the preferred initial high-intensity statin because it is clinically and cost effective for the primary and secondary prevention of CVD.
a) Evidence of the availability of atorvastatin 20 mg within local service providers.
Data source: Local data collection, for example, local formularies.
b) Evidence of local systems to check whether adults with CKD are taking atorvastatin 20 mg and invite them to discuss starting treatment if not.
Data source: Local data collection, for example, service specifications.
Proportion of adults with CKD who receive atorvastatin 20 mg.
Numerator – the number in the denominator who receive atorvastatin 20 mg.
Denominator – the number of adults with CKD.
Data source: Local data collection, for example, audit of health records. The National CKD Audit reports the percentage of people with coded CKD stages 3 to 5 who are on a statin.
a) Prevalence of cardiovascular disease among people with CKD.
Data source: Local data collection, for example, audit of health records. The UK Renal Registry collects data on comorbidities of renal patients, including angina, heart failure and atrial fibrillation.
b) Incidence of cardiovascular events for people with CKD.
Data source: Local data collection, for example, audit of health records. The UK Renal Registry collects data on comorbidities of renal patients, including dates of heart failure, transient ischaemic attack, stroke and ST segment elevation myocardial infarction (STEMI).
c) Cardiovascular mortality rates among people with CKD.
Data source: Local data collection, for example, audit of health records. The UK Renal Registry collects data on the cause of death of renal patients.
d) Proportion of people with CKD with a greater than 40% reduction in non‑high‑density lipoprotein cholesterol.
Data source: Local data collection, for example, audit of health records.
Service providers (general practices and secondary care services, such as renal, cardiology, diabetes and rheumatology clinics) ensure that systems are in place for adults with CKD to be offered atorvastatin 20 mg. For example, this may be done through incorporating treatment algorithms into software applications to provide users with patient-specific recommendations on treatment.
Healthcare professionals (GPs, nephrologists, cardiologists, diabetologists, rheumatologists, nurses and pharmacists) check whether adults with CKD are taking a statin, and discuss the risks and benefits of starting statin therapy if not. They offer atorvastatin 20 mg and increase the dose if an adequate response to treatment is not achieved and eGFR is 30 ml/min/1.73 m2 or more. If a person is not able to tolerate atorvastatin 20 mg or reports adverse effects, they discuss alternative options such as stopping the statin or changing the dose or type of statin.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults with CKD are offered atorvastatin 20 mg. Commissioners may do this by seeking evidence of practice through clinical audits.
Adults with CKD are at a higher risk of heart attacks and strokes. To help reduce the risk they are offered a type of medicine called a statin, which lowers the level of cholesterol (sometimes called lipids) in the blood. If their cholesterol level does not decrease enough, they may change to a higher dose. If the statin causes any side effects, their doctor might ask them to stop taking it for a while to check that they are caused by the statin. Their doctor might discuss reducing the dose or changing to a different statin.
Chronic kidney disease in adults: assessment and management (2014) NICE guideline CG182, recommendation 1.6.15
Cardiovascular disease: risk assessment and reduction, including lipid modification (2014) NICE guideline CG181, recommendation 1.3.27
CKD is defined as abnormalities of kidney function or structure present for more than 3 months, with implications for health. This includes:
people with markers of kidney damage, including albuminuria (ACR more than 3 mg/mmol), urine sediment abnormalities, electrolyte and other abnormalities due to tubular disorders, abnormalities detected by histology, structural abnormalities detected by imaging or a history of kidney transplantation
people with a glomerular filtration rate (GFR) of less than 60 ml/min/1.73 m2 on at least 2 occasions separated by a period of at least 90 days (with or without markers of kidney damage).
[NICE's guideline on chronic kidney disease in adults]