Non-HDL cholesterol and remnant cholesterol are better indicators of atherosclerotic cardiovascular disease risk than LDL cholesterol in patients with chronic kidney disease.

BACKGROUND AND AIMS: Low-density lipoprotein cholesterol (LDL-C) is the primary therapeutic target for lipid lowering, yet it may incompletely reflect atherosclerotic cardiovascular disease (ASCVD) risk in patients with chronic kidney disease (CKD). Non-high-density lipoprotein cholesterol (non-HDL-C) and remnant cholesterol (RC) capture cholesterol carried by a broader spectrum of atherogenic lipoproteins and may provide complementary information for risk stratification in this population. This study aimed to compare the associations of LDL-C, non-HDL-C, and RC with ASCVD risk and to evaluate their performance in discordant lipid profiles among patients with CKD.

METHODS

A total of 27,978 CKD patients from the Kailuan cohort were included, with a median follow-up of 13.81 years. Associations of LDL-C, non-HDL-C, and RC with incident ASCVD were assessed using Cox proportional hazards models and restricted cubic spline analyses. Discordance analyses were conducted using clinically relevant lipid cutoffs.

RESULTS

Higher levels of LDL-C, non-HDL-C, and RC were all associated with an increased risk of ASCVD. However, the associations of non-HDL-C and RC with ASCVD risk were more consistent across subgroups, whereas those for LDL-C were more heterogeneous. Compared with participants with concordantly low lipid levels, those with elevated non-HDL-C or RC but normal LDL-C had significantly higher ASCVD risk.

CONCLUSIONS

In patients with CKD, non-HDL-C and RC were more consistently associated with ASCVD risk than LDL-C. Discordance analyses suggest that these lipid parameters may improve residual ASCVD risk stratification beyond LDL-C-based assessment.