To the Editor:

In their article on A Study to Evaluate the Use of Rosuvastatin in Subjects on Regular Hemodialysis: An Assessment of Survival and Cardiovascular Events (AURORA), Fellström et al. (April 2 issue)¹ report little benefit for rosuvastatin in reducing the rates of cardiovascular events and death in patients undergoing hemodialysis.

This distinction from the effect in the general population is primarily because the cause of cardiovascular disease in patients undergoing hemodialysis is multifactorial and goes beyond the traditional atherothrombotic mechanisms.

Therefore, any study of the use of statins should elaborate on the extent of control of hyperphosphatemia² and hyperparathyroidism,² which affect vascular calcification, and the incidence of hyperhomocysteinemia³ in study patients.

In AURORA, the baseline serum phosphorus level of 1.8 mmol per liter (5.6 mg per deciliter) corresponds to the third quintile in the United States Renal Data System study (waves 1, 3, and 4), which showed an already elevated baseline risk (1.13) for adverse cardiovascular events.

Similarly, data on the incidence of left ventricular hypertrophy, a powerful predictor of cardiovascular events in patients undergoing hemodialysis,⁴ is missing from AURORA.

Given the formidable task of adjusting for so many confounding factors, it is premature to write off the role of statins in protection against cardiovascular disease in patients undergoing hemodialysis.

Anirban Ganguli, M.D. INSCOL Hospital. Chandigarh 160034, India ranaganguli19782003@yahoo.co.in

NEJM Volume 361:93-95 July 2, 2009 Number 1

http://content.nejm.org/cgi/content/full/361/1/93

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