Tag Archives: hyperlipidemia

Conflicting Cholesterol Guidelines –Massive Undertreatment or Massive Overtreatment?

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A fascinating article (Gooding HC et al. JAMA Pediatr doi:10.1001/jamapediatrics.2015.0168) studies a cross-sectional analysis of the National Health and Nutrition Examination Survery (NHANES) population and determines the frequency of the need for statin therapy for hyperlipidemia based on two separate guidelines.

  • 2011 Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents of the National Heart, Lung, and Blood Institute (Pediatrics 2011; 128 (sup 5): S213-S256) PEDS RECS
  • 2013 Guidelines on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults from the American College of Cardiology and American Heart Association (Circulation 2014: 129 (25) (supl 2) S1-S45) ADULT GUIDELINES

Specifically, the design of the study focused on 17-21 year olds in which the guidelines had overlapping recommendations. While the NHANES population involved only 6338 patients, this representative sample was used to calculate the likelihood of statin therapy more broadly among the US population of 20.4 million in this age group.

Key Findings:

  • Among the cohort of 6338, 2.5% would qualify for statin treatment using PEDS RECS compared with 0.4% under ADULT GUIDELINES.
  • This finding extrapolates to 483,500 patients nationwide compared with 78,200, respectively.  This is a difference of more than 400,000 and reflects a 6-fold difference.

Why the discrepancy?

  • ADULT GUIDELINES recommend use of statins only if LDL-C is >190. PEDS RECS extend to as low as 130 or 160 if additional risk factors (highly prevalent) are present, including hypertension, obesity, and smoking.
  • ADULT GUIDELINES are based on randomized clinical trials, though “they advocate for physician’s judgement in areas where the evidence base is insufficient.” PEDS RECS use extrapolated evidence for lifetime risk of coronary vascular disease.

Bottomline: While these guidelines highlight differences among 17-21 year olds, the decision regarding statin therapy extends across the age spectrum in terms of whether a low or high threshold should be in place.  Also, it is unfortunate that the additional modifiable risk factors (smoking, hypertension, and obesity) are so prevalent as to create this divergence in approach.

Related references:

  • NEJM 2015; 372: 1489-99. Alirocumab, a monoclonal antibody that inhibits PCSK9, lowered LDL 62% in patients receiving maximal statin therapy. Randomized, placebo-controlled study with 2341 patients.
  • NEJM 205; 372: 1500-09. Evolocumab, a monoclonal antibody that inhibits PCSK9, lowered LDL 61% in two open-label randomized trials (n=4465).

Related blog posts:

Sandy Springs

Sandy Springs

Alive and well? 10 years after liver transplantation

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As survival has improved with liver transplantation (LT), long-term health outcomes have become more important.  Reported 5-year survival rate after pediatric LT in North America is >85%.  More data on long-term health consequences are provided in a review of 167 10-year survivors from a North American Database (Studies of Pediatric Liver Transplantation –SPLIT) (J Pediatr 2012; 160: 820-6).

Ng VL et al report on frequency of comorbidities as well as quality of life.  Of the 10-year survivors who were included in this study: 85 (50.9%) were transplanted in the first year of life; 69 (41.3%) received transplants between 1-7.9 years.  Biliary atresia accounted for 55.1% of the transplanted cohort; the remainder were due to the following: metabolic liver disease 23 (13.8%), acute liver failure 18 (10.8%), other cholestatic conditions 17 (10.2%), tumor 6 (3.6%), and other 11 (6.6%).

First allograft survival rates were 94% at 1 year and 88% at 10 years.   Health-related quality of life (HRQOL) as assessed by the PedsQL 4.0 Generic Core Scales revealed lower patient self-reported total scale scores for LT survivors compared with healthy children (77.2 vs 84.9, P<.001).  14% had HRQOL >2 SDs below that of a matched healthy population.  Other specific post-LT morbidities included the following:

  • Impaired linear growth (23% <10th percentile); ongoing steroid therapy was associated with increased risk of poor linear growth.
  • Renal dysfunction (9%) –defined as calculated glomerular filtration rate <90 mL/min/1.73 m2.
  • Hyperlipidemia: 20% with hypercholesterolemia, and 26% with hypertriglyciridemia
  • Lymphoproliferative disease (5%).  EBV seroconversion occurred in 46 (47%) of 97 who had been EBV-negative prior to LT.  25 (15%) developed symptomatic EBV infection.
  • School performance: 32 (23%) had repeated a grade or were held back at least 1 school year.
  • Liver fibrosis: at 10 years, elevated aminotransferases were noted in 11% and increased gamma gluatmyl transpeptidase in 15%.  Previous studies from SPLIT indicate fibrosis is common in long-term survivors even with good clinical outcomes.

Alive and well?  While survival has improved remarkably, better outcomes are still needed.

Related posts:

Picking winners and losers with liver transplantation allocation

Good care 24/7

Big gift, how much risk

Additional references:


  • -Pediatrics 2008; 122: 1128-35.  Outcomes of 461 pediatric LT.
  • -Am J Transplant 2008; 8: 2506-13.  Improving long-term outcomes of LT.
  • -Hepatolog 2009; 49: 880-6.  LT-Liver fibrosis at 10 year followup.
  • -JPGN 2008; 47: 165. ~50% below 1.3 SD of adult height. Many show partial catch up growth.
  • -Liver Transplant 2006; 12: 1310. Review article on nutrition for OLTx patient.