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J Am Soc Nephrol 12: 341–348, 2001 Comparative Effects of Cerivastatin and on the Atherogenic Phenotype in Proteinuric Renal Disease

CHRISTOPHER J. DEIGHAN,*† MURIEL J. CASLAKE,† MICHAEL MCCONNELL,† J. MICHAEL BOULTON-JONES,* and CHRISTOPHER J. PACKARD† *Renal Unit and †Department of Pathological Biochemistry, Glasgow Royal Infirmary, Glasgow, United Kingdom.

Abstract. Patients with nephrotic-range proteinuria have im- centration (49%), RLP-C (35%), and RLP-TG (44%; all P Ͻ paired clearance of -rich . This results 0.01). Fenofibrate also reduced %LDLIII from 60 to 33% (P Ͻ in the atherogenic lipoprotein phenotype (mild hypertriglycer- 0.01). HDL-C (19%, P Ͻ 0.01) increased with fenofibrate idemia, low high-density lipoproteins [HDL], and excess treatment; LDL-C and total LDL were unchanged. The reduc- small, dense low-density lipoproteins [LDLIII]). Excess rem- tion in LDLIII concentration and RLP-C with fenofibrate treat- nant lipoproteins (RLP) are linked to and ment correlated with plasma triglyceride reduction (LDLIII r2 may contribute to the atherogenicity of nephrotic . ϭ 67%, P Ͻ 0.001; RLP r2 ϭ 58%, P Ͻ 0.005). A randomized crossover study compared the effects of a Serum creatinine increased with fenofibrate treatment (14%, P (cerivastatin) and a (fenofibrate) on LDLIII and RLP in Ͻ 0.01); however, creatinine clearance was unchanged. LD- 12 patients with nephrotic-range proteinuria. Cerivastatin re- LIII concentration was 187 Ϯ 85 mg/dl after cerivastatin duced cholesterol (21%, P Ͻ 0.01), triglyceride (14%, P Ͻ treatment and 133 Ϯ 95 mg/dl after fenofibrate treatment. 0.05), LDL cholesterol (LDL-C; 23%, P Ͻ 0.01), total LDL Cerivastatin and fenofibrate reduce LDLIII concentration in (18%, P Ͻ 0.01), and LDLIII concentration (27% P Ͻ 0.01). nephrotic-range proteinuria. However, atherogenic concentra- %LDLIII, RLP-C, and RLP triglyceride (RLP-TG) were un- tions of LDLIII remain prevalent after either treatment. Feno- changed. Plasma LDLIII reduction with cerivastatin treatment fibrate but not cerivastatin reduces remnant lipoproteins. The correlated with LDL-C reduction (r2 ϭ 34%, P Ͻ 0.05). two treatments seem to reduce LDLIII by different mecha- Fenofibrate lowered cholesterol (19%), triglyceride (41%), nisms, suggesting a potential role for combination therapy to very low-density lipoprotein cholesterol (52%), LDLIII con- optimize lowering of LDLIII and RLP.

Patients with proteinuria have an increased incidence of car- and retrospective studies have demonstrated a link between diovascular disease (1). Those with nephrotic-range proteinuria LDLIII and increased risk of (4,5), and experience a 5.5-fold increase in the relative risk of myocardial a plasma level of LDLIII Ͼ100 mg/dl confers a sevenfold infarction, even after correction for and smoking increase in the risk of myocardial infarction (6). We recently (2). More than two thirds of patients with nephrotic syndrome demonstrated that patients with nephrotic-range proteinuria have at least two risk factors for the development of athero- possess atherogenic quantities of LDLIII (7). Very low-density sclerosis (3), and the dyslipidemia that is prevalent in this lipoprotein (VLDL) can similarly be divided into large, light population is likely to contribute to the increased incidence of VLDL1 and smaller, denser VLDL2. VLDL1 and VLDL2 are . thought to be regulated independently. VLDL1 is increased in Lipoproteins exhibit heterogeneity. Low-density lipopro- patients with raised (6), whereas excess VLDL2 is teins (LDL) can be divided into large, light LDLI (d 1.025 to found in patients with increased LDL cholesterol (LDL-C) (6). 1.034 g/ml) and LDLII (d 1.034 to 1.044 g/ml), and small, In nephrotic-range proteinuria, VLDL1 clearance is delayed dense LDL (LDLIII; d 1.044 to 1.063 g/ml). LDLIII is con- and VLDL2 production is increased (8). As a result, both sidered to be the most atherogenic LDL species. Prospective subfractions are found in increased quantities (8). Pharmacological lowering with either hepatic 3-meth- ylglutaryl coenzyme A reductase inhibitors () or Received June 29, 1999. Accepted June 18, 2000. reduces cardiovascular morbidity and mortality (9–11). How- Correspondence to Dr. Christopher J. Deighan, Consultant Physician, Re- ever, the majority of patients with coronary artery disease do nal Unit, Walton Building, Glasgow Royal Infirmary, Castle Street, Glas- not have , and a large proportion have a gow, G4 0SF, UK. Phone: 0141-211-5049; Fax: 0141-211-4843; E-mail: [email protected] pattern of mild hypertriglyceridemia, low HDL, and excess LDLIII (12), known as the atherogenic lipoprotein phenotype 1046-6673/1202-0341 Journal of the American Society of Nephrology (6). In the normal populations, statins reduce LDLIII by low- Copyright © 2001 by the American Society of Nephrology ering all three LDL subfractions in concert (13). Fibrates 342 Journal of the American Society of Nephrology J Am Soc Nephrol 12: 341–348, 2001 promote a shift in LDL size toward larger, lighter particles, lesterol ester, phospholipid, and protein contents of all lipoproteins with or without a change in total LDL (14,15). Recent evidence were assayed, and lipoprotein concentrations were calculated as the suggests that remnants of triglyceride-rich lipoproteins may sum of these components. Three LDL subfractions (LDLI, d 1.025 to also be implicated in the pathogenesis of (16). 1.034 g/ml; LDLII, d 1.034 to 1.044 g/ml; and LDLIII, d 1.044 to Elevated lipoprotein remnants (RLP) are found in patients with 1.063 g/ml) were isolated from fresh plasma by nonequilibrium den- sity gradient ultracentrifugation as described previously (21). The raised plasma triglyceride (17) and therefore may contribute to individual subfraction areas were quantified and expressed as percent- the increased cardiovascular risk of the atherogenic lipoprotein age of total LDL. The lipoprotein concentration of LDL was used to phenotype. generate individual subfraction concentrations. The cholesterol and In addition to hypercholesterolemia, raised plasma triglyc- triglyceride content of remnant lipoproteins (RLP-C, RLP-TG) was eride is well recognized in nephrotic-range proteinuria (18), measured using a diagnostic reagent kit from Japan Immunoresearch with reports of 67% (8) and 71% (3) of patients having a Laboratories (JIMRO; Takasaki, Japan). RLP were separated from plasma triglyceride greater than 2 mmol/L and 2.3 mmol/L, other lipoproteins by an immunoaffinity gel containing monoclonal respectively. Statins have been shown to reduce cholesterol antibodies to human apoB100 and human apoA1 (22). The cholesterol and LDL-C in patients with nephrotic dyslipidemia (8); how- and triglyceride contents of the unbound fraction were measured using ever, this cholesterol-lowering effect is also accompanied by enzymatic spectrophotometric assays. Apolipoproteins B, CII, CIII, plasma triglyceride reduction and increased receptor-mediated and E were analyzed from ethylenediaminetetraacetate plasma using kits purchased from Wako Pure Chemical Industries (Osaka, Japan). LDL clearance (19). LDLIII formation is a consequence of mild increases in plasma triglyceride (6), and therefore the Statistical Analyses triglyceride-lowering effect of statins may have a beneficial Statistical analysis was performed using MINITAB 11 for Win- effect not only on LDLIII concentration but also on the relative dows (Minitab Inc., State College, PA) and SPSS statistical package. proportions of each LDL subfraction and on remnant lipopro- Results are shown as means Ϯ SD. Baseline and end point data were teins. The aim of this study, therefore, was to compare the compared using repeated measures ANOVA, with the two treatment ability of a statin (cerivastatin) and a fibrate (fenofibrate) to modalities further compared using paired t test if the ANOVA showed lower levels of these atherogenic lipoproteins in patients with a significant difference. Pre- and posttreatment data were compared nephrotic-range proteinuria. A secondary aim was to assess using paired t test. Regression analysis identified significant changes in VLDL subfractions and plasma apolipoproteins to correlations. help identify mechanisms that underlie any changes. Results Materials and Methods Baseline Data Patients The diagnoses of the study population were IgA nephropathy Twelve patients (10 male, 2 female) were recruited from the (four), membranous nephropathy (three), minimal change ne- Glasgow Royal Infirmary Renal Unit. Inclusion criteria were (1) phropathy (two), mesangiocapillary glomerulonephritis (two) and biopsy-proven glomerular disease, (2) urinary albumin Ͼ1.5 g/24 h focal and segmental glomerulosclerosis (one). Baseline data ob- (equivalent to 3 g proteinuria/24 h), (3) serum creatinine Ͻ250 tained before treatment are shown in Tables 1 to 3. Values at the ␮mol/L, (4) cholesterol Ͼ6.5 mmol/L, and (5) triglyceride Ͼ1.5 beginning of each treatment phase (baseline and washout) did not mmol/L. Exclusion criteria were (1) significant deterioration in renal differ for any parameter. The median age of the study patients was function in the previous 6 mo and (2) having diseases or receiving 52 yr (range, 18 to 66). Average BP was 143/87 mmHg (nine treatment that influenced lipid profile (specifically, diabetes mellitus treated with antihypertensives). The mean body mass index was ␤ or amyloid, diuretics, fat-soluble -blockers, , 27.7 Ϯ 3.6, with a serum albumin of 35.8 Ϯ 5.5 g/L (Ͻ32 g/L in or other immunosuppressants). Treatment with other antihyperten- three patients). Only one patient had significant edema. Serum sives was permitted. All lipid-lowering therapy was stopped for 4 wk creatinine was Ͼ150 ␮mol/L in 3 of 12 patients before cerivas- before the study. The study had a randomized, crossover design and lasted 5 mo. Six tatin treatment and 2 of 12 before fenofibrate treatment. Com- patients received 100 ␮g of cerivastatin for 1 mo and 200 ␮g for the pared with normal reference values, concentrations of total second month. Six patients received fenofibrate 200 mg for 2 mo. This VLDL, VLDL1, and VLDL2 were increased four- to fivefold (23), was followed by a month washout period off lipid-lowering treatment and IDL and total LDL were increased twofold (Table 2) (23). and then the alternative treatment for 2 mo. Patients were seen LDLIII was the most prevalent LDL particle (Table 3) with a monthly, after an overnight fast, and samples were taken for creati- concentration Ͼ100 mg/dl in 10 of 12 patients in each group. nine, albumin, function tests (LFT), creatine kinase (CK), RLP-C and RLP-TG both were raised at baseline (Table 3) (24). and lipoproteins, VLDL and LDL subfractions, 24-h creatinine clear- ance, and urinary albumin. The study was approved by the Ethics Clinical Data, Lipids, Lipoproteins, and Committee of Glasgow Royal Infirmary. All patients gave written Apolipoproteins consent before participating. Changes in lipids, lipoproteins, and apolipoproteins (apo) Plasma lipids and lipoproteins were measured according to the Lipid Research Clinic’s protocol. VLDL (S 60 to 400), VLDL (S after treatment with cerivastatin are shown in Table 1. Ceriv- 1 f 2 f astatin produced a significant fall in cholesterol (21%), triglyc- 20 to 60), and intermediate-density lipoprotein (IDL; Sf 10 to 20) were isolated from plasma by cumulative-gradient ultracentrifugation (20). eride (14%), and LDL-C (23%). The reduction in VLDL-C just LDL (d 1.019 to 1.063 g/ml) was isolated from fresh plasma by failed to reach significance, and no change in HDL-C was sequential ultracentrifugation. The triglyceride, free cholesterol, cho- observed. A 21% reduction in plasma apoB concentration was J Am Soc Nephrol 12: 341–348, 2001 Treatment of LDLIII in Proteinuria 343

Table 1. Basic lipid and lipoproteins: Cerivastatin versus fenofibratea

Cerivastatin Fenofibrate Parameter Baseline (mg/dl) Final Result % Decrease Final Result % Decrease (mg/dl) (95% CI) (mg/dl) (95% CI)

Creatinine (␮mol/l) 128 Ϯ 38 127 Ϯ 38 2 (Ϫ2, 7) 145 Ϯ 49d Ϫ14 (Ϫ22, Ϫ6)b Creatinine clearance (ml/min) 71 Ϯ 27 74 Ϯ 31 Ϫ4(Ϫ20, 12) 70 Ϯ 30 1 (Ϫ12, 13) UAE (g/24 h) 2.7 Ϯ 1.4 2.8 Ϯ 1.3 Ϫ4(Ϫ31, 24) 2.3 Ϯ 1.1 2 (Ϫ20, 24) Plasma cholesterol (mmol/L) 7.7 Ϯ 1.0 6.0 Ϯ 0.9 Ϫ21 (15, 27)b 6.3 Ϯ 1.0 19 (10, 27)b Plasma triglyceride (mmol/L) 3.6 Ϯ 2.6 2.8 Ϯ 2.0 14 (1, 27)c 2.2 Ϯ 1.7d 41 (31, 51)b VLDL-C (mmol/L) 1.6 Ϯ 1.1 1.1 Ϯ 0.8 16 (Ϫ4, 36) 0.7 Ϯ 0.6e 52 (32, 73)b LDL-C (mmol/L) 5.2 Ϯ 1.2 3.9 Ϯ 0.8 23 (17, 30)b 4.4 Ϯ 0.8 8 (Ϫ11, 28) HDL-C (mmol/L) 0.96 Ϯ 0.21 0.99 Ϯ 0.23 Ϫ4(Ϫ15, 7) 1.12 Ϯ 0.26e Ϫ19 (Ϫ25, Ϫ13)b ApoB (mg/dl) 178 Ϯ 34 134 Ϯ 33 21 (13, 29)b 135 Ϯ 38 27 (16, 37)b ApoCII (mg/dl) 8.6 Ϯ 3.8 7.3 Ϯ 3.4 10 (0, 21)c 6.4 Ϯ 3.4d 29 (23, 35)b ApoCIII (mg/dl) 35.1 Ϯ 8.8 31.7 Ϯ 7.8 7 (1, 14)c 26.7 Ϯ 7.5d 26 (21, 30)b ApoE (mg/dl) 6.7 Ϯ 3.8 5.0 Ϯ 3.0 20 (5, 34)c 4.5 Ϯ 2.6 32 (22, 42)b

a UAE, urine albumin excretion; VLDL-C, very low-density lipoprotein cholesterol; LDL, low-density lipoprotein; HDL, high-density lipoprotein; APO, apolipoprotein. b P Ͻ 0.01 for response to treatment with cerivastatin and fenofibrate. c P Ͻ 0.05 for response to treatment with cerivastatin and fenofibrate. d P Ͻ 0.01 for final result of cerivastatin versus fenofibrate. e P Ͻ 0.05 for final result of cerivastatin versus fenofibrate.

Table 2. Plasma lipoprotein concentrations: Cerivastatin versus fenofibrate

Cerivastatin Fenofibrate Parameter Baseline (mg/dl) Final Result % Decrease Final Result % Decrease (mg/dl) (95% CI) (mg/dl) (95% CI)

Total VLDL (mg/dl) 433 Ϯ 291 311 Ϯ 232 26 (16, 35)b 220 Ϯ 214c 55 (42, 68)b Ϯ Ϯ Ϫ Ϯ d b VLDL1 (mg/dl) 287 281 200 217 18 ( 7, 44) 135 184 57 (40, 74) Ϯ Ϯ Ϫ Ϯ d b VLDL2 (mg/dl) 147 61 112 62 14 ( 14, 43) 85 53 47 (34, 60) IDLa (mg/dl) 97 Ϯ 29 77 Ϯ 38 20 (Ϫ1, 41) 84 Ϯ 23 8 (Ϫ6, 23) Total LDL concentration (mg/dl) 447 Ϯ 90 349 Ϯ 48 18 (9, 26)b 382 Ϯ 80 14 (Ϫ1, 29)

a IDL, intermediate-density lipoprotein. b P Ͻ 0.01 for response to treatment with cerivastatin and fenofibrate. c P Ͻ 0.01 for final result of cerivastatin versus fenofibrate. d P Ͻ 0.05 for final result of cerivastatin versus fenofibrate.

Table 3. LDL subfractions and plasma lipoprotein remnants: Cerivastatin versus fenofibrate

Cerivastatin Fenofibrate Parameter Baseline (mg/dl) Final Result % Decrease Final Result % Decrease (mg/dl) (95% CI) (mg/dl) (95% CI)

LDLI concentration 42 Ϯ 42 36 Ϯ 35 24 (Ϫ5, 53) 67 Ϯ 45b Ϫ137 (Ϫ249, Ϫ26)c LDLII concentration 145 Ϯ 93 125 Ϯ 62 Ϫ2(Ϫ34, 31) 183 Ϯ 68 Ϫ87 (Ϫ191, 61) LDLIII concentration 259 Ϯ 105 187 Ϯ 85 27 (12, 41)b 133 Ϯ 95c 49 (30, 68)d RLP-Ca 45 (32 – 67) 31 (24 – 57) Ϫ2(Ϫ48, 43) 32 (19 – 42) 21 (22, 48) RLP-TGa 83 (41 – 119) 44 (27 – 152) Ϫ65 (Ϫ220, 91) 39 (18 – 69) 32 (22, 66)

a Median ϩ interquartile range. RLP-C, remnant lipoprotein cholesterol; RLP-TG, remnant lipoprotein triglyceride. b P Ͻ 0.05 for response to treatment with cerivastatin and fenofibrate. c P Ͻ 0.05 for final result of cerivastatin versus fenofibrate. d P Ͻ 0.01 for response to treatment with cerivastatin and fenofibrate. 344 Journal of the American Society of Nephrology J Am Soc Nephrol 12: 341–348, 2001 observed, with a similar decrease in apoE (20%). Smaller Cerivastatin versus Fenofibrate reductions were seen in plasma apoCII (10%) and apoCIII Clinical Data, Lipids, Lipoproteins, and Apolipoproteins. (7%). No change in serum creatinine, creatinine clearance, Lipoprotein and apolipoprotein concentrations after each treat- LFT, or CK was observed with cerivastatin treatment; how- ment were compared. Despite the greater reduction in LDL-C ever, one patient developed myalgia while receiving 200 ␮gof with cerivastatin treatment, no difference in cholesterol or cerivastatin, which resolved on decreasing to a 100-␮g dosage. LDL-C was observed (Table 1). Plasma triglyceride (P Ͻ 0.01) No increment in CK was found. and VLDL-C (P Ͻ 0.05) were lower with fenofibrate treat- Fenofibrate treatment resulted in large reductions in plasma ment; the absolute reduction in triglycerides and VLDL-C also triglyceride (41%) and VLDL-C (52%). A significant decrease was greater after fenofibrate treatment compared with cerivas- in plasma cholesterol (19%) was also seen, with a 19% in- tatin treatment (mean difference: TG, 0.8 mmol/L; 95% CI, crease in HDL-C. Plasma apoB (27%), apoE (32%), apoCII 0.4:1.3; VLDL-C, 0.5 mmol/L; 95% CI, 0.1:0.9). HDL-C was (29%), and apoCIII (26%) all were significantly reduced. No higher with fenofibrate treatment (P Ͻ 0.05); there was a consistent change in LDL-C was observed. Fenofibrate treat- greater increment with fenofibrate treatment compared with ment was associated with a 14% increase in serum creatinine cerivastatin treatment (difference, 0.15 mmol/L; 95% CI, 0.06: (P Ͻ 0.01); however, there was no change in creatinine clear- 0.25). With treatment, plasma apoB and apoE concentrations ance. One patient developed abnormal LFT and a rise in CK did not differ. Plasma apoCII (P Ͻ 0.01) and apoCIII (P Ͻ after 2 mo of fenofibrate treatment. These values returned to 0.01) were lower with fenofibrate treatment. Serum creatinine normal after stopping the drug as planned. Overall, there was was higher with fenofibrate treatment, but no difference in no significant change in CK after fenofibrate treatment (mean creatinine clearance was observed (Table 1). increase, 78 ␮/L; 95% confidence interval [CI], Ϫ105:261). Lipoproteins, LDL Subfractions, and Lipoprotein Rem- Ͻ Ͻ nants. Total VLDL (P 0.01), VLDL1 (P 0.05), and VLDL (P Ͻ 0.05) all were lower with fenofibrate treatment VLDL, VLDL Subfractions, IDL, and LDL 2 compared with cerivastatin treatment (Table 2). The absolute Concentration reduction in total VLDL and VLDL was also greater with Cerivastatin produced a significant reduction in the concen- 2 fenofibrate treatment (difference: total VLDL, 118 mg/dl; 95% tration of total VLDL (26%) and total LDL (18%; Table 2). CI 29:207; VLDL , 39 mg/dl; 95% CI, 12:66). The difference Changes in VLDL subfractions and IDL were more heteroge- 2 in VLDL reduction did not reach significance (79 mg/dl; 95% neous (Table 2) with an 18% reduction in VLDL (mean 1 1 CI, Ϫ13:170). With treatment, IDL and LDL concentrations decrease, 80 mg/dl; 95% CI, 19:141), a 14% reduction in were not different. VLDL (mean decrease, 29 mg/dl; 95% CI, Ϫ4:61), and a 2 LDLIII concentration was lower (P Ͻ 0.05) and LDLI nonsignificant reduction in IDL concentration (mean decrease, concentration was higher (P Ͻ 0.01) with fenofibrate treatment 21 mg/dl; 95% CI, Ϫ2:43). Fenofibrate induced large reduc- compared with cerivastatin treatment. The absolute changes in tions in total VLDL, VLDL , and VLDL (Table 2). The LDL 1 2 LDLI and LDLIII concentration also differed. Fenofibrate in- reduction showed marked heterogeneity (mean decrease, 74 creased whereas cerivastatin decreased LDLI concentration mg/dl; 95% CI, 1:146). IDL concentration did not change. (mean difference, 33 mg/dl; 95% CI, 4:62). The reduction in LDLIII with fenofibrate treatment was greater than with cer- LDL Subfractions and Lipoprotein Remnants ivastatin treatment (mean difference, 63 mg/dl; 95% CI, Ϫ7: Plasma LDLIII concentration fell by 27% with cerivastatin 134; P Ͻ 0.07). The increase in %LDLI and the decrease in treatment (Table 3). LDLI concentration was very low, and a %LDLIII both were greater with fenofibrate treatment com- negligible change in LDLII was observed. The relative per- pared with cerivastatin treatment (Figure 1; both P Ͻ 0.03). A centage of each LDL subfraction did not change (pre-cerivas- greater reduction in RLP-C and RLP-TG was found with tatin %LDLI, 9 Ϯ 7; %LDLII, 31 Ϯ 16; %LDLIII, 60 Ϯ 23; post-cerivastatin %LDLI, 10 Ϯ 9; %LDLII, 36 Ϯ 16; %LD- LIII, 54 Ϯ 24). Cerivastatin treatment failed to reduce levels of either RLP-C (mean decrease, 9 mg/dl; 95% CI, Ϫ8:26) or RLP-TG (mean decrease, 20 mg/dl; 95% CI, Ϫ32:73; Table 3). Fenofibrate reduced LDLIII concentration (mean decrease, 131 mg/dl; 95% CI, 77:184; P Ͻ 0.0005; Table 3), with a corresponding increase in LDLI (26 mg/dl; 95% CI 5:46; P Ͻ 0.02; Table 3). The relative proportions of each LDL subfrac- tion therefore changed with a shift in particle size toward larger, lighter particles. Thus, %LDLIII decreased from 60 to 33% (95% CI, 12:41; P Ͻ 0.01), whereas %LDLI and %LDLII both increased (%LDLI, 8 to 19%; 95% CI, 3:19; %LDLII, 32 to 48%; 95% CI, 1:30; both P Ͻ 0.05, all absolute change). A significant reduction in both RLP-C (16 mg/dl; 95% CI, 8:25) Figure 1. Absolute change in percentage of low-density lipoprotein and RLP-TG (43 mg/dl; 95% CI, 9:77) was observed. (%LDL) subfraction: Cerivastatin versus Fenofibrate (mean Ϯ SEM). J Am Soc Nephrol 12: 341–348, 2001 Treatment of LDLIII in Proteinuria 345 fenofibrate treatment; however, the final RLP-C and RLP-TG r2 ϭ 40.0%, P Ͻ 0.04) but not in plasma triglyceride (RLP-C concentrations did not differ. r2 ϭ 15.0%, P ϭ NSD [Figure 3]; RLP-TG r2 ϭ 12.1%, P ϭ Factors Correlated with LDLIII and RLP Reduction. NSD). In addition, plasma LDLIII reduction with fenofibrate The plasma triglyceride reduction after fenofibrate treatment treatment correlated with both RLP-C (r2 ϭ 44.6%, P Ͻ 0.02; 2 ϭ Ͻ 2 ϭ ϭ correlated with decreases in both VLDL1 (r 70.5%, P Figure 4) and RLP-TG (r 35.0%, P 0.05) reduction. 0.001) and LDLIII concentration (r2 ϭ 67.5%, P Ͻ 0.001;

Figure 2). The correlation between VLDL1 and plasma LDLIII Discussion reduction just failed to reach significance (r2 ϭ 30%, P Ͻ The main findings of this study are that in patients with 0.07). No correlation was noted between changes in LDLIII nephrotic-range proteinuria, both fenofibrate and cerivastatin and either LDL-C (Figure 2) or total LDL concentration. In significantly reduce plasma concentration of LDLIII; fenofi- contrast, after cerivastatin treatment, no relationship was ob- brate but not cerivastatin lowers atherogenic RLP. The data served between plasma triglyceride reduction and decreases in show that cerivastatin reduces plasma cholesterol, LDL-C, and plasma LDLIII (Figure 2) or VLDL1. However, an association triglyceride, whereas fenofibrate reduces plasma triglyceride was observed between the reduction in LDL-C and the de- with a lesser decrease in cholesterol and a significant increase crease in LDLIII (r2 ϭ 33.7%, P Ͻ 0.05; Figure 2). in HDL-C. It is noteworthy that the two treatments seem to The reduction in RLP after fenofibrate treatment was asso- differ in the mechanism by which they reduce LDLIII; ceriv- 2 ϭ Ͻ ciated with decreases in VLDL1 (RLP-C r 60.7%, P astatin lowers LDLIII concentration by reducing the total LDL, 0.004 [Figure 3]; RLP-TG r2 ϭ 68.3%, P Ͻ 0.002) and plasma independent of any effect on the LDL pattern. In contrast, the triglyceride (RLP-C r2 ϭ 58.2%, P Ͻ 0.005 [Figure 3]; marked reduction in LDLIII with fenofibrate treatment results RLP-TG r2 ϭ 55.5%, P Ͻ 0.005). With cerivastatin treatment, from a shift in LDL size toward larger, lighter particles without the change in RLP was also associated with the change in any effect on total LDL. Fenofibrate produced a lower final 2 ϭ Ͻ VLDL1 (RLP-C r 39.5%, P 0.03 [Figure 3]; RLP-TG LDLIII concentration compared with cerivastatin and proved

Figure 2. Percentage change in plasma triglyceride (TG) and LDL cholesterol (LDL-C) versus small, dense LDL (LDLIII) concentration for fenofibrate and cerivastatin. 346 Journal of the American Society of Nephrology J Am Soc Nephrol 12: 341–348, 2001

Figure 3. Percentage change in plasma TG and very low-density lipoprotein1 (VLDL1) concentration versus remnant lipoprotein cholesterol (RLP-C) for fenofibrate and cerivastatin.

more effective in lowering potentially atherogenic remnants of triglyceride-rich lipoproteins. However, despite successful lipid reduction (27% reductions in LDLIII with cerivastatin treatment and 49% reduction with fenofibrate treatment), atherogenic levels of LDLIII remain with both drug regimens. The finding that fenofibrate improved plasma triglyceride, VLDL-C, and HDL-C without a reduction in LDL-C is similar to that found in nonproteinuric populations, in which the ability of fibrates to lower LDL-C is known to be related to baseline triglyceride concentrations. As a result, the greatest decreases in LDL are seen in patients with normal plasma triglyceride levels (14,25), whereas in mixed , as here, fi- brates often fail to reduce LDL-C (25,26). This response has been reported with other fibrates in nephrotic dyslipidemia (27). In contrast, cerivastatin reduced cholesterol and LDL-C, Figure 4. Percentage change in RLP-C versus LDLIII concentration with a lesser but still significant effect on triglycerides. This for fenofibrate. lipid-lowering effect is similar to that found in nonproteinuric J Am Soc Nephrol 12: 341–348, 2001 Treatment of LDLIII in Proteinuria 347 populations and with other statins in large-scale intervention tabolism unchanged (13). However, in mixed hyperlipidemia, studies (9,10). of which proteinuria is an example, statins increase catabolism A dramatic shift in the quality of LDL was seen after of both VLDL-TG and VLDL-C (28). Our study is in keeping fenofibrate treatment. At the beginning of therapy, the predom- with this hypothesis with cerivastatin reducing triglyceride-rich inant LDL subfraction was LDLIII. After treatment, the pro- VLDL1, with a modest (but not quite significant) reduction in portion that was LDLIII fell, so that larger, lighter LDLII cholesterol ester–enriched VLDL2. That the statin failed to became the major species present. This response was markedly reduce remnant lipoproteins significantly is surprising because uniform; the concentration of LDLIII fell in all 12 patients. In these drugs are effective in type III hyperlipidemia, where rem- contrast, cerivastatin did not shift the particle size distribution, nants accumulate in the circulation (29). It is noteworthy, how- despite a reduction in both plasma triglyceride and VLDL1. ever, that changes in RLP after statin treatment were associated This is possibly because the reduction in VLDL1, which ac- with the changes in VLDL1. Thus, the failure of cerivastatin to cording to published models (6) is critical in determining reduce RLP may result from the heterogeneity of the change in

LDLIII, was less than that seen with fenofibrate treatment. VLDL1 (ranging from a 70% decrease to a 63% increase). Nevertheless, a consistent change was seen with cerivastatin Although fenofibrate treatment was associated with an in- treatment, with a reduction in LDLIII concentration in 11 of 12 crease in serum creatinine, no change in creatinine clearance patients. Overall, fenofibrate treatment resulted in a larger was observed. An increase in serum creatinine has been re- reduction in LDLIII and lower final LDLIII concentration ported in patients who have impaired renal function and who compared with cerivastatin treatment. are treated with fenofibrate, without any change in either Potential mechanisms that underlie the changes in LDLIII creatinine clearance or GFR (30). However, the precise effect after treatment with fenofibrate and cerivastatin are further of fenofibrate on renal function is not clear and will require elucidated by examining the relationship between the changes more detailed study. It is noteworthy that most fibric acid in plasma triglycerides, LDL-C, VLDL subfractions, and LD- derivatives are protein bound and may accumulate in patients LIII. After fenofibrate therapy, triglyceride reduction is asso- with impaired renal function. ciated with the decrease in both VLDL1 and LDLIII concen- In conclusion, it is evident that simply looking at the plasma tration. A weak relationship is also seen between the reduction cholesterol and LDL-C does not allow full assessment of the in VLDL1 and LDLIII. Excess triglycerides (in the form of cardiovascular risk posed by dyslipidemia in patients with VLDL1) promote LDLIII formation by allowing triglyceride nephrotic-range proteinuria. The atherogenic lipoprotein phe- enrichment of LDL (via cholesterol ester transfer protein– notype is a common finding that is not necessarily expressed as mediated exchange). This makes LDL a better substrate for an increase in LDL. RLP are a component of the phenotype, lipolysis by hepatic lipase (6). Thus, the association between which respond to fibrate but not to statin therapy, and athero- triglyceride reduction and LDLIII reduction with fenofibrate genic concentrations of LDLIII continued to be prevalent after treatment supports the role of hypertriglyceridemia in LDLIII treatment. We suggest that cardiovascular protection should formation. With cerivastatin treatment, the reduction in LDL-C aim to reduce not only total cholesterol but also LDLIII and is associated with the decrease in LDLIII. It is likely that the RLP. drug reduces LDLIII by reducing the amount of LDL available for conversion to LDLIII and therefore lowering LDLIII by a different mechanism to fenofibrate. We suggest that there may Acknowledgments be a future role for combined therapy to achieve greater re- This study was performed with the aid of a grant from the Scottish ductions in plasma concentration of LDLIII. Hospital’s Endowment Research Trust (SHERT). Parts of this study were The changes in RLP after treatment parallel changes seen presented in abstract form at the Scottish Renal Association, May 1999. The lipid-lowering drugs used in this study were supplied by Fournier with the LDL phenotype. It is recognized that plasma triglyc- Pharmaceuticals (fenofibrate) and plc (cerivastatin). eride is the best marker for high levels of RLP (17). Fenofi- brate, by improving lipolysis, reduces remnants by 35 to 45%, with a close association between triglyceride reduction and References RLP reduction. This hypothesis is supported by the association 1. 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