Dyslipidemia and chronic kidney disease

“Paul,” a jovial, somewhat rotund (height 67.5"; weight 248 lbs) 79-year-old came to the clinic with his wife of 58 years, both wondering why he was seeing yet another doctor. “We feel well, we are very happy together; enjoy our children, grandchildren and great grandchildren, and can do anything we want!”

Indeed he was feeling far healthier than his numbers would suggest. He had type 2 diabetes on treatment with metformin and exenatide (Byetta, Amylin) with an HbA1c of 5.5% to 6.1% over the past 12 months. The big problem was his lipid profile with a triglyceride level of 500 to 600, HDL <10, and directly measured LDL hovering around 120. These values had been stable for about 18 months.

In 2006 he experienced a sharp drop in kidney function for which an etiology had not been found and since then his estimated glomerular filtration rate fluctuated between 25 and 35 cc/min/1.73 m² — basically stage III chronic kidney disease as defined by the Kidney Disease Outcomes Quality Initiative guidelines developed by the National Kidney Foundation.

I have searched PubMed, KDOQI, Wikipedia and Google trying to determine the optimal treatment for this type of lipidemia — all to no avail. To be sure, every search led me to one or more articles confirming that this lipid profile is common in CKD, and additional reading material presenting hypotheses to explain the profile. But I found nothing that could really direct my approach to therapy.

I discontinued the exenatide because both hypertriglyceridemia and exenatide have been linked to acute pancreatitis so the combination seemed an invitation to trouble ahead. Additionally his diabetes was well controlled as assessed by the HbA1c (checking of course that it was not artificially lowered by a high red cell turnover) and the absence of any hypoglycemic episodes.

He had been given niacin in the past, but he could not tolerate it because of severe hot flashes.

Diet modification would be a nice idea but not very acceptable to this couple who enjoyed their current diet and were not keen to change.

At his first clinic visit I prescribed Omega-3-ethyl esters (Lovaza, GlaxoSmithKline) 2 g orally twice per day before meals and he tolerated this well. After four weeks of therapy his lipid profile was unchanged — not a great surprise. I have added gemfibrozil 600 mg, also orally twice per day before meals and will re-check his levels in late January. He made it quite clear that the family could tone down the Thanksgiving festivities but Christmas was the big family holiday for which they were responsible and he had no intentions of changing the time-honored menu in any way. Hard to get too fussed over that, but I did suggest that he be little more careful himself. His smile said it all! Let’s see what the January profile brings.