Approach to pharmacologic lipid-lowering therapy in adults with persistent nephrotic syndrome who do not have indications for primary or secondary CVD prevention

CVD: cardiovascular disease; LCL-C: low-density lipoprotein cholesterol; eGFR: estimated glomerular filtration rate.
* Our preference for waiting up to 3 to 6 months after initiation of treatment of the nephrotic syndrome to determine the need for pharmacologic therapy is an arbitrary threshold, and some clinicians may choose to initiate pharmacologic therapy earlier or later in the course of treatment. We feel that it is reasonable to wait up to 6 months to start pharmacologic therapy since it is unclear that delaying therapy for up to this amount of time is associated with an increased long-term risk of CVD in this population.
¶ All patients with indications for primary or secondary CVD prevention based upon their estimated CVD risk and eGFR should receive lipid-lowering therapies as appropriate. In patients with persistent nephrotic syndrome who do not have indications for primary or secondary CVD prevention, we use LDL-C to guide decisions on lipid-lowering therapy since it is unclear that CVD risk can be accurately estimated with risk calculators in such patients. However, there is no high-quality evidence to support the use of this (or any other) LDL-C threshold in patients with the nephrotic syndrome; this threshold is similar to that used for non-nephrotic patients without established CVD who are at very high risk for a CVD event.
Δ Refer to UpToDate content on the use of statin therapy in patients with the nephrotic syndrome for details on choice of agent and dosing. If statin therapy is not tolerated, a PCSK9 inhibitor, fibrate, or bile acid sequestrant is a potential alternative option.
◊ The optimal LDL-C target in patients with the nephrotic syndrome is not known. We titrate the therapy to target an LDL-C goal of ≤100 mg/dL in view of the increased CVD risk in patients with the nephrotic syndrome.
§ There is no consensus agreement on the serum triglyceride level above which therapy to lower triglycerides should be initiated. We consider severe hypertriglyceridemia to be a serum triglyceride level >400 mg/dL.
¥ If the nephrotic syndrome eventually resolves with treatment, pharmacologic lipid-lowering therapy can be discontinued unless indicated for primary or secondary CVD prevention based upon the patient's CVD risk and eGFR. If the patient has persistent albuminuria or eGFR is <60 mL/min/1.73 m², we continue therapy indefinitely.