An Under-Recognized, and Under-Treated, Complication of Nephrotic Syndrome

Dyslipidemia causes renal injury and is implicated in higher rates of atherosclerosis with nephrotic syndrome, but it is still not well understood, particularly in children.

Columbus, OH — March 2018

Moderate-to-severe hyperlipidemia is almost universal in people with persistent nephrotic syndrome. It is a major risk factor in the acceleration of cardiovascular disease, and because of lipid-related renal injury, likely itself has a role in the pathogenesis of nephrotic syndrome.

But especially in children, it is not given the attention it should be. A recent review of dyslipidemia in nephrotic syndrome, led by physicians and researchers at Nationwide Children’s Hospital, highlights both the importance of addressing abnormal lipid levels and gaps in existing knowledge about how to do it.

The paper appears in Nature Reviews Nephrology.

“We should realize that dyslipidemia is very common and a reason for concern in patients with nephrotic syndrome,” says William E. Smoyer, MD, a nephrologist at Nationwide Children’s, director of the hospital’s Center for Clinical and Translational Research and senior author of the review. “When those patients are children, we should also realize how little evidence exists about how best to manage that dyslipidemia.”

While dyslipidemia in adults may be the result of pre-existing conditions, dyslipidemia in children with nephrotic syndrome is usually directly related to the nephrotic syndrome, says Dr. Smoyer, who is also a professor of Pediatrics at The Ohio State University College of Medicine. When nephrotic syndrome is not able to be effectively treated to induce remission of the disease, treatment of its complications such as chronic dyslipidemia becomes an important part of the long-term care of such patients.

Recommendations for diet and activity changes often come first, even though studies showing their effect on lowering blood lipid levels were based only on an examination of healthy adults. The authors of the review suggest that statins should be the first-line pharmacological treatment for adults, because they are well tolerated and have proven effective in the treatment of other diseases. A pilot trial of atorvastatin in children with nephrotic syndrome is ongoing, but the results are not yet known.

The authors also note that inhibitors of the enzyme PCSK9 have shown promising results in treating dyslipidemia alone, which will almost certainly prompt trials investigating their efficacy in nephrotic syndrome-related dyslipidemia. 

“We still have a long way to go in our understanding of the role of dyslipidemia in the progression of glomerular disease, as well as of the development of more effective treatments for it,” says Dr. Smoyer.

Reference:

Agrawal S, Zaritsky JJ, Fornoni A, Smoyer WE. Dyslipidaemia in nephrotic syndrome: mechanisms and treatment. Nature Reviews Nephrology. 2018 Jan;14(1): 57-70.