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Why no target for lowering lipids in CKD?

When chronic kidney disease appeared as a new clinical domain in the QOF, we were told it was a risk factor for coronary heart disease.

I immediately started to wonder how poor kidney function was linked to CHD. I asked my clinical tutor and my QOF visiting team but nobody seemed to have an answer. My instinct was that it could be high lipid levels depositing in the microvasculature, causing poor renal function and eventually CHD.

To answer my questions, I decided to audit CKD patients as part of my appraisal project. I looked at patients with an eGFR below 60 but who had not yet developed hypertension, diabetes or CHD. I found 25 such patients at my practice.

I looked at age, eGFR, fasting cholesterol, blood pressure, smoking history, protein levels, additional illnesses and medications.

Lo and behold, I found something - high lipid levels in all but two very thin women. None of these patients was on lipid-lowering therapy.

Two others had obstructive pathology of prostate hypertrophy and one had cancer.

Dare I conclude that we maybe need to concentrate on lowering cholesterol in CKD patients more than on bringing their blood pressure down? It seems so obvious.

Why then are we being asked to bring blood pressure down to faintingly low levels, and why is there no QOF indicator to require low lipid levels for patients with CKD?

Dr Archana Garg, Leyland, Lancashire

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