Non-high-density lipoprotein cholesterol: a target of lipid-lowering in dialysis patients

The finding of an increased prevalence and levels of atherogenic lipoproteins in the context of normal plasma total and low-density lipoprotein (LDL) cholesterol (LDL-C) levels in hemodialysis (HD) patients highlights the need to look beyond the basic assessment of plasma concentrations of total cholesterol and LDL-C. Measurement of atherogenic lipoproteins (remnant lipoprotein particles [RLPs], particularly intermediate-density lipoprotein [IDL]), is not routinely performed at the present time.

The National Cholesterol Education Program guidelines indicate that the secondary goal in persons with triglyceride levels greater than 200 mg/dL is non-high-density lipoprotein cholesterol (HDL-C). Non-HDL-C comprises all RLPs, including IDL, as well as atherogenic small dense LDL.

We propose, for practical reasons, that non-HDL-C be used as a primary target in HD patients when lipid-lowering therapy is indicated. However, it remains unclear whether and how effective statins are in lowering remnant particle levels in dialysis patients. Recent data show that both simvastatin and atorvastatin reduce non-HDL-C levels effectively. Atorvastatin preferentially reduces RLP levels in patients with combined hyperlipidemia.

The safety profile of statins predisposes prescription of this class of drugs to correct dyslipidemia or modulate lipoprotein particle composition in uremic patients. Whether atorvastatin influences myocardial infarction or all-cause mortality by adequately correcting dyslipidemia should be seen fairly quickly in the 1,252 dialysis patients with diabetes randomly assigned in the ongoing Die Deutsche Diabetes Dialyse study.