Cholesterol is a type of blood fat which is made in the liver. Cholesterol plays a vital role in the body, but having too much can lead to health problems, including heart disease.

Statins are a group of medicines that can help lower cholesterol in the blood.

These life-saving drugs have been used by millions of people for more than 30 years, but reports about possible side effects can deter some from taking them, so they miss out on their protective effects. We spoke to three medical experts about the benefits and risks of statins specifically for people with CKD.

How are heart disease and kidney disease connected?

It’s important to remember that your kidneys, heart, and blood vessels are all interconnected, and that doctors treat the whole body holistically, not just one organ in isolation.

‘If you have heart disease, your kidney function is likely to get worse, and having kidney disease will increase your risk of heart disease,’ explains Dr Vivian Yiu, consultant nephrologist at West Suffolk Hospital and East of England Renal Network lead for chronic kidney disease.

In fact, people with CKD are 20 times more likely to die from cardiovascular disease than of kidney failure.

Just having CKD raises the risk of cardiovascular disease, including strokes, heart attacks and peripheral vascular disease in the legs, explains Beverley Bostock, Queen’s Nurse Advanced Nurse Practitioner and President Elect of the Primary Care Cardiovascular Society.

‘Whilst statins aren’t specifically a treatment for CKD, they help the heart which is put under pressure if the kidneys aren’t working well,’ says Beverley. ‘Poor kidney function can raise blood pressure and damage blood vessels and put a strain on the heart.’

What are statins?

‘Statins are drugs that are taken daily to lower cholesterol, a fatty substance in the blood which can fur up arteries and cause a lot of damage to blood vessels which can then lead to heart attack and strokes,’ says Beverley.

‘Most cholesterol – 80 per cent – is made in the liver and only a small amount comes from diet. Statins work by telling the liver to calm down and stop making so much cholesterol.’

What are the benefits of statins for people living with CKD?

Statins are recommended for all people who are living with CKD, from early to late stages, apart from dialysis patients. This includes transplant patients, as even after a transplant patients still have CKD.

‘Patients with CKD at all stages have an increased risk of developing cardiovascular diseases including heart attacks, strokes and peripheral vascular disease, or damage to the blood vessels in the legs,’ says Dr Yiu.

‘Statins not only lower cholesterol, but also have anti-inflammatory effects, which is important as inflammation has been shown to be responsible for a lot of the damage caused in chronic diseases as a whole.’

Beverley adds that statins also stabilise plaques that have built-up in the arteries, which means they are less likely to rupture and cause a heart attack. ‘We see that plaques begin to disappear and be less of a problem.’

What kinds of statins are available? 

• Atorvastatin is recommended by the National Institute for Health and Care Excellence (NICE) for primary prevention for people who haven’t had a heart attack or stroke. NICE guidelines recommend high intensity treatment with a daily dose of atorvastatin for all people with chronic kidney disease.
• Another high strength statin called rosuvastatin can be prescribed if you don’t respond to atorvastatin or have side effects. ‘This is a more powerful drug so we can use it in much smaller doses to get the same effect,’ says Beverley. ‘The bottom line is that low doses of rosuvastatin will be fine for people with CKD while the higher doses would be avoided.’

There are other types of statins that can be tried, such as pravastatin, simvastatin and fluvastatin, but they are not as powerful as atorvastatin and rosuvastatin.

‘Some statins are more intense and are more effective at lowering cholesterol, but you may get more side effects,’ advises Kathrine Parker, Specialist Renal Pharmacist at Manchester University NHS Foundation Trust.

‘New research has shown that side effects from statins are rarer than previously reported, but if you do experience them, don’t stop taking your medication, talk to your health professional about changing the dose or the type of statin you are taking.’

Are some statins more kidney-friendly than others?

Most CKD patients will be started on atorvastatin, says Kathrine.

‘Rosuvastatin is more renally cleared (they are excreted by the kidney more), so smaller doses may need to be used. It may not be suitable for some people if their kidney function is very low.’

What are the possible side effects of statins?

New research has found that statins do not cause the majority of potential side effects that have been associated with them. A review, which was part funded by the British Heart Foundation and published in scientific journal The Lancet, looked at 19 large, high-quality randomised-controlled trials, which compare patients taking treatment with a control group who don’t. The review that found that only four side effects out of a possible 66 were linked to statins.

Dr Yiu says the review found the risk of side effects overall was low and has been overstated in the past. ‘For those who did have muscle aches and pains, these symptoms weren’t usually caused by statins,’ she explains.

‘The main side effect was a change in liver function, but that only showed up in blood tests and patients didn’t actually get any symptoms from it. A small change, for example in the type of statins or dose, usually eliminated it.’

To help you understand more about taking statins, Kathrine recommends Should I take a statin?, a NICE decision aid to help you talk about your options with your healthcare team. It explains the benefits of statins, as well as the risk of potential side effects. It is for people who do not already have heart disease and have not had a stroke.

Can statins damage your kidneys?

‘The short answer is that statins don’t damage your kidneys,’ says Kathrine. ‘The only instance of this is where they can cause an extremely rare side effect called rhabdomyolysis, rapid muscle breakdown. Unless treated, rhabdomyolysis releases toxins that can cause kidney failure, but it affects less than 0.1 per cent of statin users.’

What if I don’t want to take statins?

No one is going to force you to take statins, and there are alternative drugs for you to consider. However, for the vast majority of people with CKD, the benefits in terms of reducing your chances of heart attacks and stroke far outweigh the risks of side effects. Speak to your doctor, nurse or pharmacist so they can answer your questions.

‘Apart from the obvious risk of death, there is a significant lowering of your quality of life if you have a heart attack or stroke. For instance, if you have a heart attack and your heart muscle is damaged, you might end up being really short of breath because your heart doesn’t pump properly and it's impossible to reverse the damage done. But statins help prevent all these downstream effects,’ says Dr Yiu.

Are there any alternatives to statins?

‘There are alternatives to statins for lowering cholesterol, although none of them are as effective as statins, which can lower cholesterol by 40 per cent at high doses and 30 per cent at lower doses,’ says Dr Yiu. Other cholesterol-lowering medication includes:

• Ezetimibe, a once-a-day tablet that works by blocking absorption of cholesterol from food in your stomach into the bloodstream. NICE says these can be prescribed for people who cannot take statins due to side effects or alongside statins for those  who need extra help. ‘It doesn’t particularly affect kidney function, which makes it an appealing option for people with CKD, but it doesn’t have the anti inflammatory effects of statins and is not quite as effective,’ says Dr Yiu.
• Bempedoic acid: A daily pill that is taken on its own or with ezetimibe.
• PCSK9 inhibitors: These are injections given every 2 to 4 weeks; they lower cholesterol in the blood by blocking a protein called PCSK9 which is made in the liver. NICE currently recommends these be used only in people who have had a heart attack or stroke, if a maximum dose statin has not reduced their cholesterol enough, or they have an inherited high cholesterol condition.
• Inclisiran: This is a twice-yearly injection that turns off the gene that controls production of PCSK9. NICE recommends it only for people who have had a heart attack or stroke.

How do I get the best effect from taking statins?

‘A healthy diet can help lower your cholesterol but it’s not enough usually on its own. A healthy diet complements statins, not replaces them – the two work together,’ says Beverley.

‘Physical activity can raise your ‘good’ HDL cholesterol, which is protective against heart disease. I advise people to start by doing more exercise than they are currently doing and work towards the government’s recommended activity level of 150 minutes a week.’

Giving up smoking and drinking no more than 14 units of alcohol a week is also beneficial if you are on statins (alcohol raises the risk of side effects).

What food, drink, and medicines do I need to be careful with when taking statins and living with CKD?

‘Grapefruit juice is something to be cautious about if you are taking certain statins, particularly simvastatin but also atorvastatin,’ says Kathrine. This is because it can inhibit an enzyme called CYP3A4 which breaks these statins down, causing too much of the drug to stay in the body and increasing the risk of muscle damage and liver side effects.

‘There are some herbal medicines and supplements such as turmeric and CBD oil that you can buy over the counter that interact with simvastatin and atorvastatin, so we have a general rule that you should always check with your community pharmacist or kidney team before starting any of these. Normal amounts of turmeric in foods are fine.’

Kathrine says some prescribed drugs including some oral antifungals and some antibiotics can also interact with statins, but these interactions should be picked up by alerts on GP and hospital prescribing systems.

Heart UK, the cholesterol charity, offers detailed patient information and guidance about statins and other cholesterol-lowering medication, as well as expert support to help you look after your heart health.