Statins and All-Cause Mortality in Patients Undergoing Hemodialysis

Abstract

Background Recommendations have not yet been established for statin therapy in patients on maintenance dialysis. In this study, we aimed to evaluate the effects of statin therapy on all-cause mortality in patients undergoing maintenance hemodialysis. Methods and Results This retrospective cohort study analyzed data from adults, aged ≥30 years, who were on maintenance hemodialysis for end-stage renal disease. Data on statin use, along with other clinical information between 2007 and 2017, were extracted from the Health Insurance Review and Assessment Service database in Korea. In total, 65 404 patients were included, and 41 549 (73.2%) patients had received statin therapy for a mean duration of 3.6±2.6 years. Compared with statin nonusers before and after the initiation of hemodialysis (entry), patients who initiated statin therapy after entry and patients who continued statins from the pre-end-stage renal disease to post-end-stage renal disease period had a lower risk of all-cause mortality; the adjusted hazard ratios (95% CIs) were 0.48 (0.47-0.50; P<0.001) for post-end-stage renal disease only statin users and 0.59 (0.57-0.60; P<0.001) for continuous statin users. However, those discontinuing statins before or at entry showed a higher risk of all-cause mortality. Statin-ezetimibe combinations were associated with better survival benefits than fixed patterns of statin therapy. These results were consistent across various subgroups, including elderly patients aged >75 years, and were maintained even after propensity score matching. Conclusions Our results showed that in adult patients undergoing maintenance hemodialysis, statin therapy, preferably combined with ezetimibe, was associated with a lower risk of all-cause mortality.

Keywords: all‐cause mortality; end‐stage renal diseases; hemodialysis; statin.

Figure 1

Flow diagram of participant inclusion in the study. ESRD indicates end‐stage renal disease.

Figure 2

Multiple (age, sex, and Charlson Comorbidity Index) adjusted survival plots for all‐cause mortality related to statin therapy, according to various conditions in adult patients undergoing maintenance hemodialysis. A, Statin ever‐users vs nonusers. B, Statin use before and after entry (the initiation of hemodialysis). C, The intensity of statin therapy. Note that the plot lines for variable and moderate intensities of statin therapies overlap completely. D, Prescription maintenance of statin therapy, as determined by the proportion of days covered (PDC). Note that the plot lines for the 2 PDC groups (25%–<50% and 50%–<75%) overlap completely. ESRD indicates end‐stage renal disease.

Figure 3

Multiple (age, sex, Charlson Comorbidity Index, and ezetimibe use) adjusted survival plots for all‐cause mortality related to statin therapy, according to ezetimibe combination in adult patients undergoing maintenance hemodialysis. A, Nonmatched survival plot. B, Survival plot after propensity score matching (1:≈2) for statin nonusers and statin users. ESRD indicates end‐stage renal disease.