Association of Continuation of Statin Therapy Initiated Before Transition to Chronic Dialysis Therapy With Mortality After Dialysis Initiation

Elani Streja, Elvira O. Gosmanova, M. Molnár, Melissa Soohoo, Hamid Moradi, Praveen K. Potukuchi, Kamyar Kalantar-Zadeh, Csaba P. Kovesdy

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Abstract

Importance: De novo statin therapy in patients receiving chronic dialysis has failed to demonstrate cardiovascular (CV) protection in randomized clinical trials and thus is not recommended by current guidelines. However, current guidelines recommend the continuation of statin therapy if initiated before transition to dialysis. Objective: To investigate whether the continuation of statins from advanced chronic kidney disease into the dialysis therapy period is associated with improved survival. Design, Setting, and Participants: Retrospective cohort study of US veterans transitioning to dialysis between October 1, 2007, and March 30, 2014. Participants were 14 298 US veterans who were receiving statins during the 12-month period before transition to dialysis and survived the first year of dialysis. Data analysis was conducted between August 2, 2017, and June 28, 2018. Exposures: Patients were characterized as statin continuers (n = 11 936) if statin therapy was continued for at least 6 months during the first year after dialysis initiation and as statin discontinuers (n = 2362) if therapy with statins was stopped or no statin therapy was received in the year posttransition. Main Outcomes and Measures: Associations of statin continuation with 12-month all-cause mortality and CV mortality after 1 year of dialysis initiation were examined using Cox proportional hazards regression models adjusted for demographics and comorbidities. Results: The mean (SD) age of the cohort was 71 (10) years; the cohort was 96.7% (n = 13 828) male and 21.3% (n = 3043) African American, and 74.6% (n = 10 627) had diabetes. The 12-month all-cause mortality and CV mortality rates after 1 year of transition to dialysis were lower in statin continuers: deaths per 100 person-years were 21.9 (95% CI, 20.9-22.8) and 8.1 (95% CI, 7.5-8.6) in statin continuers vs 30.3 (95% CI, 27.8-32.8) and 9.8 (95% CI, 8.3-11.2) in statin discontinuers. Moreover, lower all-cause mortality and CV mortality risks with statin continuation persisted in adjusted analyses, with hazard ratios of 0.72 (95% CI, 0.66-0.79) and 0.82 (95% CI, 0.69-0.96), respectively. Associations were similar across subgroups, including age, race, and diabetes status. Conclusions and Relevance: In this study, the continuation of statin therapy after transition to dialysis was associated with reduced all-cause mortality and CV mortality. The study findings suggest that future studies are needed to examine potential CV benefits of continuing statin therapy after dialysis initiation.

Original languageEnglish
Pages (from-to)e182311
JournalJAMA network open
Volume1
Issue number6
DOIs
Publication statusPublished - Oct 5 2018

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Hydroxymethylglutaryl-CoA Reductase Inhibitors
Dialysis
Mortality
Therapeutics
Veterans
Guidelines

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Association of Continuation of Statin Therapy Initiated Before Transition to Chronic Dialysis Therapy With Mortality After Dialysis Initiation. / Streja, Elani; Gosmanova, Elvira O.; Molnár, M.; Soohoo, Melissa; Moradi, Hamid; Potukuchi, Praveen K.; Kalantar-Zadeh, Kamyar; Kovesdy, Csaba P.

In: JAMA network open, Vol. 1, No. 6, 05.10.2018, p. e182311.

Research output: Contribution to journalArticle

Streja, Elani ; Gosmanova, Elvira O. ; Molnár, M. ; Soohoo, Melissa ; Moradi, Hamid ; Potukuchi, Praveen K. ; Kalantar-Zadeh, Kamyar ; Kovesdy, Csaba P. / Association of Continuation of Statin Therapy Initiated Before Transition to Chronic Dialysis Therapy With Mortality After Dialysis Initiation. In: JAMA network open. 2018 ; Vol. 1, No. 6. pp. e182311.
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abstract = "Importance: De novo statin therapy in patients receiving chronic dialysis has failed to demonstrate cardiovascular (CV) protection in randomized clinical trials and thus is not recommended by current guidelines. However, current guidelines recommend the continuation of statin therapy if initiated before transition to dialysis. Objective: To investigate whether the continuation of statins from advanced chronic kidney disease into the dialysis therapy period is associated with improved survival. Design, Setting, and Participants: Retrospective cohort study of US veterans transitioning to dialysis between October 1, 2007, and March 30, 2014. Participants were 14 298 US veterans who were receiving statins during the 12-month period before transition to dialysis and survived the first year of dialysis. Data analysis was conducted between August 2, 2017, and June 28, 2018. Exposures: Patients were characterized as statin continuers (n = 11 936) if statin therapy was continued for at least 6 months during the first year after dialysis initiation and as statin discontinuers (n = 2362) if therapy with statins was stopped or no statin therapy was received in the year posttransition. Main Outcomes and Measures: Associations of statin continuation with 12-month all-cause mortality and CV mortality after 1 year of dialysis initiation were examined using Cox proportional hazards regression models adjusted for demographics and comorbidities. Results: The mean (SD) age of the cohort was 71 (10) years; the cohort was 96.7{\%} (n = 13 828) male and 21.3{\%} (n = 3043) African American, and 74.6{\%} (n = 10 627) had diabetes. The 12-month all-cause mortality and CV mortality rates after 1 year of transition to dialysis were lower in statin continuers: deaths per 100 person-years were 21.9 (95{\%} CI, 20.9-22.8) and 8.1 (95{\%} CI, 7.5-8.6) in statin continuers vs 30.3 (95{\%} CI, 27.8-32.8) and 9.8 (95{\%} CI, 8.3-11.2) in statin discontinuers. Moreover, lower all-cause mortality and CV mortality risks with statin continuation persisted in adjusted analyses, with hazard ratios of 0.72 (95{\%} CI, 0.66-0.79) and 0.82 (95{\%} CI, 0.69-0.96), respectively. Associations were similar across subgroups, including age, race, and diabetes status. Conclusions and Relevance: In this study, the continuation of statin therapy after transition to dialysis was associated with reduced all-cause mortality and CV mortality. The study findings suggest that future studies are needed to examine potential CV benefits of continuing statin therapy after dialysis initiation.",
author = "Elani Streja and Gosmanova, {Elvira O.} and M. Moln{\'a}r and Melissa Soohoo and Hamid Moradi and Potukuchi, {Praveen K.} and Kamyar Kalantar-Zadeh and Kovesdy, {Csaba P.}",
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T1 - Association of Continuation of Statin Therapy Initiated Before Transition to Chronic Dialysis Therapy With Mortality After Dialysis Initiation

AU - Streja, Elani

AU - Gosmanova, Elvira O.

AU - Molnár, M.

AU - Soohoo, Melissa

AU - Moradi, Hamid

AU - Potukuchi, Praveen K.

AU - Kalantar-Zadeh, Kamyar

AU - Kovesdy, Csaba P.

PY - 2018/10/5

Y1 - 2018/10/5

N2 - Importance: De novo statin therapy in patients receiving chronic dialysis has failed to demonstrate cardiovascular (CV) protection in randomized clinical trials and thus is not recommended by current guidelines. However, current guidelines recommend the continuation of statin therapy if initiated before transition to dialysis. Objective: To investigate whether the continuation of statins from advanced chronic kidney disease into the dialysis therapy period is associated with improved survival. Design, Setting, and Participants: Retrospective cohort study of US veterans transitioning to dialysis between October 1, 2007, and March 30, 2014. Participants were 14 298 US veterans who were receiving statins during the 12-month period before transition to dialysis and survived the first year of dialysis. Data analysis was conducted between August 2, 2017, and June 28, 2018. Exposures: Patients were characterized as statin continuers (n = 11 936) if statin therapy was continued for at least 6 months during the first year after dialysis initiation and as statin discontinuers (n = 2362) if therapy with statins was stopped or no statin therapy was received in the year posttransition. Main Outcomes and Measures: Associations of statin continuation with 12-month all-cause mortality and CV mortality after 1 year of dialysis initiation were examined using Cox proportional hazards regression models adjusted for demographics and comorbidities. Results: The mean (SD) age of the cohort was 71 (10) years; the cohort was 96.7% (n = 13 828) male and 21.3% (n = 3043) African American, and 74.6% (n = 10 627) had diabetes. The 12-month all-cause mortality and CV mortality rates after 1 year of transition to dialysis were lower in statin continuers: deaths per 100 person-years were 21.9 (95% CI, 20.9-22.8) and 8.1 (95% CI, 7.5-8.6) in statin continuers vs 30.3 (95% CI, 27.8-32.8) and 9.8 (95% CI, 8.3-11.2) in statin discontinuers. Moreover, lower all-cause mortality and CV mortality risks with statin continuation persisted in adjusted analyses, with hazard ratios of 0.72 (95% CI, 0.66-0.79) and 0.82 (95% CI, 0.69-0.96), respectively. Associations were similar across subgroups, including age, race, and diabetes status. Conclusions and Relevance: In this study, the continuation of statin therapy after transition to dialysis was associated with reduced all-cause mortality and CV mortality. The study findings suggest that future studies are needed to examine potential CV benefits of continuing statin therapy after dialysis initiation.

AB - Importance: De novo statin therapy in patients receiving chronic dialysis has failed to demonstrate cardiovascular (CV) protection in randomized clinical trials and thus is not recommended by current guidelines. However, current guidelines recommend the continuation of statin therapy if initiated before transition to dialysis. Objective: To investigate whether the continuation of statins from advanced chronic kidney disease into the dialysis therapy period is associated with improved survival. Design, Setting, and Participants: Retrospective cohort study of US veterans transitioning to dialysis between October 1, 2007, and March 30, 2014. Participants were 14 298 US veterans who were receiving statins during the 12-month period before transition to dialysis and survived the first year of dialysis. Data analysis was conducted between August 2, 2017, and June 28, 2018. Exposures: Patients were characterized as statin continuers (n = 11 936) if statin therapy was continued for at least 6 months during the first year after dialysis initiation and as statin discontinuers (n = 2362) if therapy with statins was stopped or no statin therapy was received in the year posttransition. Main Outcomes and Measures: Associations of statin continuation with 12-month all-cause mortality and CV mortality after 1 year of dialysis initiation were examined using Cox proportional hazards regression models adjusted for demographics and comorbidities. Results: The mean (SD) age of the cohort was 71 (10) years; the cohort was 96.7% (n = 13 828) male and 21.3% (n = 3043) African American, and 74.6% (n = 10 627) had diabetes. The 12-month all-cause mortality and CV mortality rates after 1 year of transition to dialysis were lower in statin continuers: deaths per 100 person-years were 21.9 (95% CI, 20.9-22.8) and 8.1 (95% CI, 7.5-8.6) in statin continuers vs 30.3 (95% CI, 27.8-32.8) and 9.8 (95% CI, 8.3-11.2) in statin discontinuers. Moreover, lower all-cause mortality and CV mortality risks with statin continuation persisted in adjusted analyses, with hazard ratios of 0.72 (95% CI, 0.66-0.79) and 0.82 (95% CI, 0.69-0.96), respectively. Associations were similar across subgroups, including age, race, and diabetes status. Conclusions and Relevance: In this study, the continuation of statin therapy after transition to dialysis was associated with reduced all-cause mortality and CV mortality. The study findings suggest that future studies are needed to examine potential CV benefits of continuing statin therapy after dialysis initiation.

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