先講在前面,文長,偏硬,慎入。
2015年三月份,KDOQI於“美國腎臟病期刊”中發表了,針對慢性腎臟病(CKD)患者的高血脂用藥建議。針對之前KDIGO的建議,提出了一些看法,以下整理。
1.1 所有新診斷CKD的患者,應該檢驗總膽固醇、三酸甘油脂、低密度與高密度膽固醇(Cholesterol, triglycerides, LDL & HDL)。
1.2 之後追蹤血脂肪數據能夠:1. 幫助判斷患者是否規則服藥,也就是用藥遵從度。2. 幫助判斷是否有達到預期療效(如:LDL下降30%的目標),進一步決定是否需要增加藥物劑量。為此,新的建議是開始用藥之後,3周至三個月應該追蹤數據一次,若達到預期療效,則後續可不用再追蹤。這是修正過的“射後不理”做法,因為就算控制達到目標,也建議維持劑量不要減量,所以,追蹤數據就變得浪費資源了。另外,小於50歲的CKD患者,如果還未達用藥標準,由於隨著疾病進展,血脂肪可能還會有變化,所以每年追蹤一次是合理的。
2.1.1 超過50歲以上、且腎功能小於60(ml/min/1.73 m2)之CKD患者,應該加上statin類(或 statin/ezetimibe)藥物治療高血脂。劑量和一般人一樣,若需要用到高劑量時(尤其是發生急性冠心病時),注意副作用仍可小心使用。
2.1.1 超過50歲以上、且腎功能大於60(ml/min/1.73 m2)之CKD患者,這個族群的實驗數據頗為缺乏,但仍然建議使用一般人的劑量,加上statin類藥物治療高血脂。
2.2 小於50歲以下者,若有1. 已知冠心病、2. 糖尿病、3. 缺血性中風、4. 10年內冠心症機率>10%,以上四點其中之一者,須使用statin藥物治療。新的建議中補充:如果LDL≥190 mg/dL(常見於腎病症候群的年輕患者,因為蛋白尿的關係,LDL常常升高),即使沒有上述危險因子,也應加上statin治療高血脂。
2.3.1 洗腎患者若新診斷高血脂,無法建議statin治療,主要是因為AURORA、4D、SHARP這三個大型研究當中,在洗腎患者這個族群都未能看到對於預後的好處,醫學就是這樣,還是強調有幾分證據說幾分話。而這次KDOQI的建議當中,則是採取較為個人化的調整:發生急性冠心症的患者、或年紀輕、有希望換腎成功者、或預期壽命很長者,可以考慮使用statin治療(雖然還是沒有強烈證據啦)。
2.3.2 若是進入洗腎之前的患者,就已經在使用statin治療者,則建議繼續使用,因為SHARP研究確實看到對預後有好處,所以不用停藥。
2.3.1與2.3.2這兩點整理討論時,作者承認,因為沒有很多研究佐證,很難提出證據來支持是否應該治療,所以,這個是否治療的決定,可以與患者好好溝通,給予個人化的選擇。換句話說,因為沒有對錯,所以可以採取大家都能接受的方式來執行。
2.4 已經接受腎臟移植的患者,建議用statin治療(ALERT trial支持這樣的建議),但要小心“抗排斥藥物”當中,很多都會和statin藥物有交互作用,所以一定要從低劑量開始使用,再小心往上調整。
3.1 有CKD的孩童,新診斷時,須常規的檢驗總膽固醇、三酸甘油脂、低密度與高密度膽固醇(Cholesterol, triglycerides, LDL & HDL)。
3.2 有CKD的孩童,每年應該追蹤一次空腹的血脂肪數據。因為孩童的臨床變動比較大,疾病進展也和成人不大一樣。
4.1 小於18歲的,有腎臟病的孩童,無法建議使用statin治療,主要也是因為沒有研究證實對預後有幫助,某種程度上可以說是研究的極限,因為研究的一大敵人就是時間,十年的研究看不出來好處,那15或20年呢?所以,這一點,目前沒有建議。
5.1 和 6.1 是指不管成人或孩童,有高三酸甘油脂血症(triglycerides)的話,都應該改善生活型態(飲食或運動)。
還是那句老話,使用任何治療之前,都應該與您的醫師討論喔!
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Sarnak MJ, Bloom R, Muntner P, et al. KDOQI US Commentary on the 2013 KDIGO Clinical Practice Guideline for Lipid Management in CKD.
American Journal of Kidney Diseases. 2015;65(3):354-366.
http://doi.org/10.1053/j.ajkd.2014.10.005