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Potential effects of reclassifying CKD as a coronary heart disease risk equivalent in the US population
Meredith C Foster1, Andreea M Rawlings1, Elizabeth Marrett2
1Department of Epidemiology and the Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health and Medical Institutions, Baltimore, MD.
Insights
Many adults with chronic kidney disease (CKD) exceed LDL cholesterol goals. Treating CKD as a coronary heart disease (CHD) risk equivalent would significantly increase the number of individuals needing cholesterol-lowering therapy.
Area of Science:
- Cardiovascular Medicine
- Nephrology
- Public Health
Background:
- Persons with chronic kidney disease (CKD) face elevated cardiovascular disease (CVD) risks but are not classified as such in current US cholesterol guidelines.
- This study investigates the impact of modifying guidelines to consider CKD a "coronary heart disease (CHD) risk equivalent" for risk stratification.
Purpose of the Study:
- To evaluate the effect of incorporating CKD as a CHD risk equivalent into US cholesterol treatment guidelines.
- To determine the proportion of adults with LDL cholesterol above treatment targets under current and modified guidelines.
Main Methods:
- A nationally representative cross-sectional study using data from 4,823 adults (aged 20+) from the 2007-2010 National Health and Nutrition Examination Survey.
- Cardiovascular risk was stratified using current US cholesterol guidelines and two simulated scenarios where CKD stages 3-5 or CKD stages 1-5 were treated as CHD risk equivalents.
- Outcomes measured included the proportion of individuals with LDL cholesterol above treatment targets and those recommended for lipid-lowering therapy initiation or intensification.
Main Results:
- In 2010, 55.1 million US adults did not meet LDL cholesterol goals; 25.2 million required lipid-lowering therapy initiation, and 12.1 million needed therapy intensification.
- Considering CKD stages 3-5 as a CHD risk equivalent increased the number above LDL goals to 59.2 million, with 28.5 million meriting initiation and 13.3 million intensification.
- Classifying CKD stages 1-5 as a CHD risk equivalent further raised the numbers to 65.2 million above goal, with 33.9 million for initiation and 14.4 million for intensification.
Conclusions:
- Current US cholesterol guidelines result in a large number of adults not meeting LDL cholesterol targets.
- Modifying guidelines to classify CKD as a CHD risk equivalent would substantially increase the number of individuals identified as needing cholesterol management.
- These findings highlight the need to reassess current cholesterol treatment guidelines for individuals with chronic kidney disease.
Background:
Persons with chronic kidney disease (CKD) are at high risk for cardiovascular disease events, but are not classified as such in current US cholesterol treatment guidelines. We examined potential effects of modified guidelines in which CKD was considered a "coronary heart disease (CHD) risk equivalent" for risk stratification.
Study Design:
Nationally representative cross-sectional study.
Setting & Participants:
4,823 adults 20 years or older from the 2007-2010 National Health and Nutrition Examination Survey.
Predictors:
Cardiovascular risk stratification based on current US cholesterol treatment guidelines and 2 simulated scenarios in which CKD stages 3-5 or CKD stages 1-5 were considered a CHD risk equivalent.
Outcomes & Measurements:
Proportion of persons with low-density lipoprotein (LDL) cholesterol at levels above treatment targets and above the threshold for lipid-lowering therapy initiation, based on current guidelines and the 2 simulated scenarios.
Results:
Under current guidelines, 55.1 million adults in 2010 did not achieve the target LDL cholesterol goal. Of these, 25.2 million had sufficiently elevated levels to meet recommendations for initiating lipid-lowering therapy; 12.1 million were receiving this therapy but remained above goal. When CKD stages 3-5 were considered a CHD risk equivalent, 59.2 million persons were above target LDL cholesterol goals, with 28.5 million and 13.3 million meriting therapy initiation and intensification, respectively. When CKD stages 1-5 were considered a CHD risk equivalent, 65.2 million adults were above goal, with 33.9 million and 14.4 million meriting therapy initiation and intensification, respectively.
Limitations:
CKD and LDL cholesterol defined using a single laboratory value.
Conclusions:
Many adults in the United States currently do not meet recommended goals for LDL cholesterol levels. Modifying the current cholesterol guidelines to include CKD as a CHD risk equivalent would lead to a substantial increase in both the number of persons with levels above LDL cholesterol treatment targets and those recommended to initiate lipid-lowering therapy.
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