title: Intestinal cholesterol absorption, treatment with atorvastatin, and cardiovascular risk in hemodialysis patients.
abstract: BACKGROUND
  Hemodialysis patients are high absorbers of intestinal cholesterol; they benefit less than other patient groups from statin therapy, which inhibits cholesterol synthesis.
  
  
  OBJECTIVE
  This study sought to investigate whether the individual cholesterol absorption rate affects atorvastatin's effectiveness to reduce cardiovascular risk in hemodialysis patients.
  
  
  METHODS
  This post-hoc analysis included 1,030 participants in the German Diabetes and Dialysis Study (4D) who were randomized to either 20 mg of atorvastatin (n=519) or placebo (n=511). The primary endpoint was a composite of major cardiovascular events. Secondary endpoints included all-cause mortality and all cardiac events. Tertiles of the cholestanol-to-cholesterol ratio, which is an established biomarker of cholesterol absorption, were used to identify high and low cholesterol absorbers.
  
  
  RESULTS
  A total of 454 primary endpoints occurred. On multivariate time-to-event analyses, the interaction term between tertiles and treatment with atorvastatin was significantly associated with the risk of reaching the primary endpoint. Stratified analysis by cholestanol-to-cholesterol ratio tertiles confirmed this effect modification: atorvastatin reduced the risk of reaching the primary endpoint in the first tertile (hazard ratio [HR]: 0.72; p=0.049), but not the second (HR: 0.79; p=0.225) or third tertiles (HR: 1.21; p=0.287). Atorvastatin consistently significantly reduced all-cause mortality and the risk of all cardiac events in only the first tertile.
  
  
  CONCLUSIONS
  Intestinal cholesterol absorption, as reflected by cholestanol-to-cholesterol ratios, predicts the effectiveness of atorvastatin to reduce cardiovascular risk in hemodialysis patients. Those with low cholesterol absorption appear to benefit from treatment with atorvastatin, whereas those with high absorption do not benefit.
authors.affiliation: Division of Angiology, Swiss Cardiovascular Center, Inselspital, University of Bern, Bern, Switzerland. Electronic address: guenther.silbernagel@insel.ch.
authors.forename: Günther
authors.initials: G
authors.lastname: Silbernagel
authors.affiliation: Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria.
authors.forename: Günter
authors.initials: G
authors.lastname: Fauler
authors.affiliation: Mannheim Institute of Public Health, Social and Preventive Medicine, Mannheim Medical Faculty, University of Heidelberg, Mannheim, Germany; Institute of Public Health, Federal University of Bahia, Salvador, Brazil; BG Stats Consulting, Vienna, Austria.
authors.forename: Bernd
authors.initials: B
authors.lastname: Genser
authors.affiliation: Division of Nephrology, Department of Internal Medicine 1, University of Würzburg, Würzburg, Germany; Comprehensive Heart Failure Centre, University of Würzburg, Würzburg, Germany.
authors.forename: Christiane
authors.initials: C
authors.lastname: Drechsler
authors.affiliation: Division of Nephrology, Department of Internal Medicine 1, University of Würzburg, Würzburg, Germany; Comprehensive Heart Failure Centre, University of Würzburg, Würzburg, Germany.
authors.forename: Vera
authors.initials: V
authors.lastname: Krane
authors.affiliation: Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria.
authors.forename: Hubert
authors.initials: H
authors.lastname: Scharnagl
authors.affiliation: Institute of Public Health, Federal University of Bahia, Salvador, Brazil.
authors.forename: Tanja B
authors.initials: TB
authors.lastname: Grammer
authors.affiliation: Division of Angiology, Swiss Cardiovascular Center, Inselspital, University of Bern, Bern, Switzerland.
authors.forename: Iris
authors.initials: I
authors.lastname: Baumgartner
authors.affiliation: Division of Nephrology, Department of Internal Medicine 1, University of Heidelberg, Heidelberg, Germany.
authors.forename: Eberhard
authors.initials: E
authors.lastname: Ritz
authors.affiliation: Division of Nephrology, Department of Internal Medicine 1, University of Würzburg, Würzburg, Germany; Comprehensive Heart Failure Centre, University of Würzburg, Würzburg, Germany.
authors.forename: Christoph
authors.initials: C
authors.lastname: Wanner
authors.affiliation: Medical Clinic 5 (Nephrology, Hypertensiology, Endocrinology, Diabetology, and Rheumatology), Mannheim Medical Faculty, University of Heidelberg, Mannheim, Germany; Synlab Academy, Synlab Services GmbH, Mannheim, Germany.
authors.forename: Winfried
authors.initials: W
authors.lastname: März
mesh_terms: D000368:Aged; D000069059:Atorvastatin; D002318:Cardiovascular Diseases / Q000453:epidemiology / Q000517:prevention & control*; D004083:Cholestanol / Q000097:blood; D002784:Cholesterol / Q000378:metabolism*; D005260:Female; D006538:Heptanoic Acids / Q000627:therapeutic use*; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use*; D007408:Intestinal Absorption; D007676:Kidney Failure, Chronic / Q000150:complications / Q000378:metabolism* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D011758:Pyrroles / Q000627:therapeutic use*; D006435:Renal Dialysis
chemical_list: D006538:Heptanoic Acids; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D011758:Pyrroles; D004083:Cholestanol; D002784:Cholesterol; D000069059:Atorvastatin
keywords: cholestanol; mortality; randomized controlled trial; statin