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Journal Club 10 June 2015


Intestinal Cholesterol Absorption, Treatment With Atorvastatin, and Cardiovascular Risk in Hemodialysis Patients





Hemodialysis patients are high absorbers of intestinal cholesterol; they benefit less than other patient
groups from statin therapy, which inhibits cholesterol synthesis.


This study sought to investigate whether the individual cholesterol absorption rate affects atorvastatin’s
effectiveness to reduce cardiovascular risk in hemodialysis patients.


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 ¼ 519) or placebo (n ¼ 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.


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 ¼ 0.049), but not the
second (HR: 0.79; p ¼ 0.225) or third tertiles (HR: 1.21; p ¼ 0.287). Atorvastatin consistently significantly reduced allcause
mortality and the risk of all cardiac events in only the first tertile.


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.

Supplementary Material

The editorial is available here.

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