The new lipid guideline makes reduced kidney function a reason for a statin. In 2024, most such patients had no statin prescription
In nearly two million US adults in 2024, statin prescriptions were lower at more advanced stages of kidney disease, the opposite of how risk usually drives treatment. A baseline before the 2026 ACC/AHA guideline.
The background
The 2026 ACC/AHA multisociety dyslipidemia guideline changed the role of kidney disease. Chronic kidney disease used to be a "risk enhancer" that nudged clinicians toward treatment. Now an eGFR between 15 and 60 (CKD stages G3 and G4) is an indication for a statin in itself, as diabetes is. For people without such an indication, the guideline uses the PREVENT 10-year risk equation, which includes eGFR and, when available, albuminuria.
What the study did
Dr. Michael Kim, Dr. Morgan Grams and colleagues, led from NYU, asked how well US practice already matched the new advice. They used the Optum Labs Data Warehouse, a de-identified database of claims and electronic health records, and included 1,956,559 adults aged 40 to 79 with an eGFR of at least 15 in 2024. People on dialysis were excluded. The outcome was any prescription for a statin, ezetimibe or a PCSK9 inhibitor during 2024.
What they found
- About half of people with atherosclerotic cardiovascular disease (48.9%) had a statin prescription, compared with 22.0% of those without.
- Among people without cardiovascular disease, 45.1% of those with diabetes had a statin, compared with 16.7% of those without diabetes.
- Where kidney function is the reason for treatment (no cardiovascular disease, no diabetes), statin prescriptions ran from 22% to 28% in stage G3a, 18% to 28% in G3b, and 9% to 23% in G4, depending on albuminuria. The lowest figure, 9%, was in stage G4 without recorded albuminuria.
- After adjustment, the odds of a statin prescription compared with stage G1 to G2 were about the same in G3a, 20% lower in G3b and about 40% lower in G4. Having cardiovascular disease, having diabetes and a higher PREVENT score all went with more statin prescriptions. The authors call this a risk-treatment paradox.
- Ezetimibe was rarely prescribed, and PCSK9 inhibitors were at 2% or less in every group.
Why it matters
The authors note that statins have consistent benefit across groups, with the exception of people on maintenance hemodialysis, and that in the SHARP trial simvastatin plus ezetimibe reduced major atherosclerotic events by 17% compared with placebo in people with CKD. They suggest better electronic health record integration, clinical decision support, prescriber and patient education, and more closely aligned specialty guidelines. Our take: nephrology clinics see many of the stage G3b and G4 patients with the largest gap and are well placed to close it.
Caveats
Our caveats: the data show prescriptions, not whether patients took the drug, and cannot say why a statin was not prescribed: intolerance, a patient's choice and prescriptions outside the database are all possible. The data come from one large commercial database and may not represent every population. They describe 2024, before the 2026 guideline, so they are a baseline rather than a measure of guideline uptake, although the authors point out that the new guideline largely aligns with longstanding KDIGO advice.
Funding and ties: the study was funded by the National Institutes of Health. Some coauthors report industry ties, listed with the paper; for example, Dr. Brendon Neuen reports consulting and speaking for several pharmaceutical companies.
The source: Kim M, Flaherty CM, Sang Y, Mavromatis LA, Neuen BL, Reynolds HR, Shin J-I, Grams ME. Lipid-Lowering Therapy in Individuals with CKD. Clin J Am Soc Nephrol. Published online ahead of print 2026 (research letter). doi:10.2215/CJN.0000001218 Read the original
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Physician-led, AI-assisted. Dr. Wael Hussein chooses every item NephSpace covers and reviews and edits every story before it is published. The first draft was written in our own words with AI (Claude, by Anthropic) from the full text of the paper and checked against our reading notes; Dr. Hussein then reviewed and edited it. For education and information only, not medical advice. Please talk to your own physician or care team about your health. Clinicians: read the original before changing practice. See our disclaimer and disclosures. Spotted an error? Tell us.
