Post on 14-Jan-2016
Evidence-Based MedicineA CKD patient with dyslipidemiaReported by R2 Instructed by Dr.
Our Patient40:150,:60,(BMI:26.7 Kg/m2) (GFR: 20.2 ml/min):135/85 mmHg,14,;
HemogramHb: 10 g/dl, Hct: 31%.UrinalysisProtein (+),RBC: 2/HPF,WBC:3/HPF. Our Patient
Our PatientBiochemistry: Uric acid: 6.0 mg/dlTriglyceride: 180 mg/dlTotal cholesterol: 225 mg/dl HDL: 40 mg/dl LDL: 140 mg/dlAC sugar: 100 mg/dlElectrolyte: Cr: 3.5 mg/dlNa: 138 mEq/L K: 4.0 mEq/LAlb: 4.0 g/dl Ca: 8.8 mg/dl P: 4.8 mg/dl
,,.??Our Patient
5As of EBMAsk : ask an answerable questionAcquire : track down the best evidenceAppraisal : validity, impact, applicabilityApply : to patients problemAudit : effectiveness
Ask an answerable questionPatient : CKD, PredialysisDyslipidemiaProteinuriaIntervention : Lipid lowering medicationComparison : Without lipid lowering medicationOutcome : All cause mortalityRenal outcome
Acquire track down the best evidenceGuidelinePrimary journal or databaseSecondary journal or database
Acquire track down the best evidenceGuidelinePrimary journal or databaseSecondary journal or database
Published Guideline
GuidelineCountryYearStage of CKDLipidTreatmentKDOQIUSA2003Stage 3,4,51.LDL 100-1292.LDL > 1303.TG > 200 & non-HDL > 1301.TLC2.TLC+low dose statin3.TLC+low dose statinCARIAustralia2005CKD PtTC > 166LDL > 100TG > 200Initiate statin if LDL > 100
Other GuidelinesEBPG (2002) : Dialysis patientBRA (2002) : Dialysis patientCSN (2005) : No guideline available
Ask an answerable questionPatient : CKD, PredialysisDyslipidemiaProteinuriaIntervention : StatinComparison : Without statinOutcome : All cause mortalityRenal outcome
Acquire track down the best evidenceGuidelinePrimary journal or databaseSecondary journal or database
Secondary Database
HMG CoA reductase inhibitors (statins) for people with chronic kidney disease not requiring dialysis. - Level 1aHMG CoA reductase inhibitors (statins) for kidney transplant recipients. - Level 1aHMG CoA reductase inhibitors (statins) for dialysis patients. - Level 1aEffect of pitavastatin on urinary liver-type fatty-acid-binding protein in patients with nondiabetic mild chronic kidney disease. - Level 2bA randomized trial of the effect of statin and fibrate therapy on arterial function in CKD. - Level 1bAcute effect of simvastatin on inflammation and oxidative stress in chronic kidney disease. - Level 2b
HMG CoA reductase inhibitors (statins) for people with chronic kidney disease not requiring dialysis. - Level 1aHMG CoA reductase inhibitors (statins) for kidney transplant recipients. - Level 1aHMG CoA reductase inhibitors (statins) for dialysis patients. - Level 1aEffect of pitavastatin on urinary liver-type fatty-acid-binding protein in patients with nondiabetic mild chronic kidney disease. - Level 2bA randomized trial of the effect of statin and fibrate therapy on arterial function in CKD. - Level 1bAcute effect of simvastatin on inflammation and oxidative stress in chronic kidney disease. - Level 2b
Acquire track down the best evidenceGuidelinePrimary journal or databaseSecondary journal or database
Primary Database
Appraisal Validity, Impact, aPplicability
CochraneStatin for people with CKD not requiring dialysisVBMJEffect of statins with CKDX
Potentially relevant articlesMedLine : 146EMBase : 367Cochrane : 70Total : 583Full text analysis : 62Included : 28(58 report)Complete : 26(52 report)Ongoing : 2(6 report)Studied excluded : 521Search overlap; Not RCT/review article; RCT, outcome not appropriate; Duration < 8wksStudied excluded : 4Non RCT/ review article : 3Duration < 8 wks : 1
Medline:Pre-Dialysis : 146Dialysis : 32Transplant : 68EMBase:Pre-Dialysis : 367Dialysis : 67Transplant : 118Cochrane:Pre-Dialysis : 38Dialysis : 14Transplant : 19Full text analysis : 68Pre-Dialysis : 146Dialysis : 32Transplant : 6850 trial, 54 comparison, 30144 PtPre-Dialysis : 26Dialysis : 11Transplant : 17Excluded : 801Search overlap : 104Not RCT/review : 693Duration < 8wks : 4Excluded : 16Duplicate reportsDuration < 8wksNon RCT
Text bookUnpublished trialNot english onlyExpert CochraneVVunclearVBMJVVVV
CochraneBMJInclusion1. RCT, quasi RCT2.Statin to Placebo/No/ Statin3.CKD - KDOQI a.Stage 3,4 b.Stage 1,2 + Proteinuria4.Baseline Cr > 1.4mg/dl5.Duration > 8wks1. RCT, quasi RCT2. Statin to Placebo/No/Statin3. CKD - KDOQI a. RRT b. Stage 3-5 c. Stage 1,2 + Proteinuria4. Baseline Cr > 1.4mg/dl5. Duration > 8wksExclusion1. ESRD2.Impaired liver function3.Elevated CPK4.Combination treatment1. Undefined renal impairment2. Impaired liver function3. Elevated CPK4. Combination treatmentOutcomeRhabdomyolysisDouble of serum Cr Allograft rejection
Allocation concealmentAdequate(A)Unclear(B)Inadequate(C)BlindingInvestigatorParticipantsassessorAnalysisIntention-to-treat analysisYesNoNo statedFollow up% of excluded
Forest Plot
Forest PlotCochran chi-square ( Cochran Q )Definite heterogeneity : P < 0.05Possible heterogeneity :No Statical significant, Q/df > 1 Heterogeneity unlikely :No Statical significant, Q/df < 1
Apply to patients problemAll Cause MortalityCVRenal outcomeGFR ProteinuriaCochraneBMJCochraneCochraneCochraneBMJBMJBMJ
Cochrane
Others
ConclusionStatins have benefit in improving mortalityStatins can improving proteinuria but cant ameliorate the progression of the GFR
Statin
For your attention
Q & AMeta-analysis versus Clinical trial ?quasi - Randomized control trial ?Heterogeneity of studies ?MESH term ?Level of evidence of guidelines ?
All Cause Mortality
All Cause Mortality
CV Mortality
CV Mortality
Renal - CrCl
Renal Proteinuria