Lipid-lowering Regimes Improve Oxidative Stress, Tryptophan Degradation in Hypercholesterolemia Chronic Kidney Disease Patients
Phase: PHASE4
Conditions: Hypercholesterolemia, Chronic Kidney Diseases
Sponsor: Hue University of Medicine and Pharmacy

STUDY PROTOCOL  
 
LIPID - LOWERING REGIMES IMPROVE OXIDATIVE STRESS, 
TRYPTOPHAN DEGRADATION IN HYPERCHOLESTEROLEMIA CKD 
PATIENTS 
 
Date of review: 03th May, 2018 
 
Brief Title: 
LIPID-LOWERING THERAPIES IN VIETNAMESE CHRONIC KIDNEY 
DISEASE POPULATION 
 
I. 
BACKGROUND 
- 
ABSTRACT/SUMMARY 
STATEMENT 
OF 
THE 
RESEARCH PROJECT: 
The prevalence of chronic kidney disease (CKD)  in Vietnamese population is 
increasing along with hypertension and diabetes. 3.1% of the population diagnosed as 
CKD (stages 3-5) with positive findings in urine test (Ito et al., 2008).  In CKD patient, 
cardiovascular disease (CVD) is the leading cause of mortality. Kidney Disease Statistics 
for the United States showed that the prevalence of CVD is 69.6 percent among person 
ages 66 and older who have CKD, compared to 34.7 percent among those who do not 
have CKD (Health, 2012). 
The lipidemic disorder is one of the cardiovascular risk factors in CKD but it was 
not fully concerned. Highest cholesterol in CKD patient is the total or low-density 
lipoprotein (LDL). 
A one-year prospective study of stage 3 or 4 CKD patients with dyslipidemia Siriraj 
Hospital showed that the percentage of patients with hypercholesterolemia was 78%, 
hypertriglyceridemia 54%, and low high-density lipoprotein-C 36% (Sangsawang & 
Sriwijitkamol, 2015). Two-thirds of CKD patients with hyperlipidemia had mixed 
hyperlipidemia. Despite the high frequency of statin treatment, only one-third of CKD 
patients achieved the LDL-C goal (Sangsawang & Sriwijitkamol, 2015). A question 
whether high-dose of statins monotherapy is more effective in LDL cholesterol lowering 
is still unclear, but high doses are associated with a high rate of hepatotoxicity, myopathy. 
Thus, we need to explore more advanced lipid-lowering therapies to manage dyslipidemia 
in patients with CKD. 
Dyslipidemia has been proposed an independent risk factor in accelerating renal 
injury (Trevisan, Dodesini, & Lepore, 2006). Statin and Statin/ezetimibe were evidenced 
to prevent cardiovascular complications in CKD patient. Co-administration of ezetimibe 
the first time enhanced proteinuria-lowering effects of pitavastatin in non-diabetic CKD 
patients partly via a cholesterol-independent manner. Ezetimibe may have pleiotropic 
actions that could contribute to renoprotective properties of this lipid-lowering agent 

(Nakamura, T., et al. (2010). However, it is still unclear if Statin and Statin/ezetimibe 
therapies can improve the renal function by proteinuria. 
Because of the high prevalence of cardiovascular morbidity and mortality in CKD 
patient, we need a better understanding of the mechanism for treatment strategy. 
Metabolomics was used in identifying new biomarkers of CKD such as acylcarnitines, 
glycerolipids, dimethylarginines and metabolites of tryptophan. C-mannosyl tryptophan 
and pseudouridine have better performance than creatinine in CKD stratification (Hocher 
& Adamski, 2017). Inflammation status was significantly reduced by treatments. There 
was no significant difference between treatments (Moutzouri et al., 2013). Endothelial 
dysfunction secondary to the pro-inflammatory and pro-oxidative state caused by 
Oxidative stress (OS) causing endothelial dysfunction secondary to the pro-inflammatory 
and pro-oxidative was observed in CKD. However, how hypolipidemic agents impact on 
Oxidative stress is still not clear. Tryptophan (Trp) degradation via indoleamine (2,3)-
dioxygenase (IDO), with consequent increased in kynurenine (Kyn) concentrations, has 
been considered as a marker of immune system activation (Schefold et al., 2009). The 
effect cholesterol-lowering treatment on oxidative and inflammation parameters in CKD 
might be mediated by restoration of antioxidant taurine concentrations, suggesting that 
amelioration of both oxidative and inflammation status in CKD patients could be partly 
explained by the cholesterol-lowering effects (Zinellu et al., 2015). 
 
In clinical practice, physicians always concern the effects and safety before giving 
the prescription. However, despite the high frequency of statin treatment, only 1/3 of 
CKD patients achieved the LDL-C goal. Whether high-dose of statins mono-therapy is 
more effective in LDL-C lowering is still unclear, but are associated with a high rate of 
hepatotoxicity, myopathy. 
Lowering LDL-C with statin mono-therapy and statin/ezetimibe combination 
reduces the risk of CVD in population without kidney disease. Which Cholesterol-
lowering therapies are suitable for stage 3,4 CKD patients in term of e-GFR reduction and 
side effects? There is no data related to this field in the Vietnamese CKD population. 
Thus, more advanced lipid-lowering therapies and a better understanding of the 
mechanism is needed for treatment strategy of hyperlipidemia in Vietnamese patients 
with CKD. The following research questions need to be addressed: 
 
(1) 
Do 
different 
lipid-lowering 
drugs 
(simvastatin 
monotherapy 
and 
ezetimibe/simvastatin combination therapy) have a different impact on the lipid profile, 
oxidative stress indices, Tryptophan degradation? 
(2) 
Does statin monotherapy or co-administration of ezetimibe ameliorate the 
renal dysfunction in CKD patients? 
(3) 
How do lipid-lowering therapy effect on lipidemia disorders in patients with 
CKD by mechanism involved in oxidative stress and tryptophan? 
(4) 
Are the unexpected effects on muscle problem and hepatic enzyme profile 
of long-term statin monotherapy and statin/ezetimibe combination therapy a big concern? 
II. REVIEW OF RESEARCH LITERATURE 

2.1. Criteria for Chronic Kidney Disease 
- Improving Global Outcomes 2012 Clinical Practice Guideline (KDIGO 2013) 
(Stevens, Levin, & for the Kidney Disease: Improving Global Outcomes Chronic Kidney 
Disease Guideline Development Work Group, 2013).  
- Either of the following present for >3 months. Markers of kidney damage (one or 
more)  
+ Albuminuria (AER >=30 mg/24 hours; ACR >=30 mg/g) 
+ Urine sediment abnormalities Electrolyte and other abnormalities due to tubular 
disorders Abnormalities detected by histology Structural abnormalities detected by 
imaging 
+ History of kidney transplantation  
+ Decreased GFR GFR <60 ml/min/1.73 m2 (GFR categories G3a–G5) 
2.2. Chronic Kidney Disease stages (Stevens et al., 2013) 
Stage 
GFR 
Treatment 
1 
90+ 
Normal kidney function but urine findings or 
structural abnormalities or genetic trait point to 
kidney disease 
2 
60-89 
Mildly reduced kidney function, and other findings 
(as for stage 1) point to kidney disease 
3A 
3B 
45-59 
30-44 
Moderately reduced kidney function 
4 
15-29 
Severely reduced kidney function 
5 
<15 or on dialysis 
Very severe, or end-stage kidney failure (sometimes 
call established renal failure) 
 
2.3. Dyslipidemia in chronic disease 
Dyslipidemia is associated with atherosclerotic vascular disease and an increased 
risk of CVD events, including acute myocardial infarction (AMI). Guidelines 
recommended aggressive lipid-lowering therapies in patients at high risk of CVD. 
Although patients with severe CKD are at high risk of CV events, the use of statins was 
limited for many reasons. Unlike individuals in the general population, patients with CKD 
are at risk of malnutrition and inflammation that have a cholesterol-lowering effect. In 42 
cases of CVD in CKD patients, cholesterol levels, and mortality risk inversely correlated 
while there was a strong and positive correlation between serum cholesterol and CVD 
mortality in the absence of inflammation and malnutrition. Because of the risk of 
rhabdomyolysis, fibrates are contraindicated in patients with renal failure.  That was one 
of the reasons why lipid-lowering agents is not popularly use in patients with CKD 
("<CKD machenism.pdf>,") 
2.4. Oxidative stress, inflammation and cardiovascular disease in chronic renal 
failure 
Traditional risk factors, as well as additional nontraditional risk factors, can 
directly damage the kidney. Some studies have shown the relationship between oxidative 
stress and inflammatory biomarkers. Some clinical studies indicated an inverse 

correlation between oxidative stress status and estimated glomerular filtration rate (eGFR) 
(Stevens et al., 2013). 
Different mechanisms could explain the oxidative stress increase in CKD. Some 
conditions of CKD patients such as advanced age, diabetes, hypertension, lower levels 
intake of the antioxidant vitamin, and failure of ROS clearance in renal function are 
related to the increase of oxidative stress and progression of CKD (Meenakshi Sundaram, 
Nagarajan, & Manjula Devi, 2014) 
2.5. Tryptophan and oxidative stress in chronic disease 
Tryptophan (Trp) plays a role of a precursor of several metabolic pathways 
involving different end products, such as proteins, serotonin, melatonin, and kynurenine 
(Ruddick, 2006). Tryptophan (Trp) degradation via indoleamine (2,3)-dioxygenase (IDO) 
has been proposed as an immune system activation marker (Schefold et al., 2009). The 
effect cholesterol-lowering treatment on oxidative and inflammation parameters in CKD 
might be mediated by restoration of antioxidant taurine concentrations, suggesting that 
amelioration of both oxidative and inflammation status in CKD patients could be partly 
explained by the cholesterol-lowering effects (Zinellu et al., 2015) 
2.6. Guidelines for the management of Dyslipidaemias ("'Ten Commandments' from 
the 2016 ESC/EAS Guidelines for the management of dyslipidaemias," 2016) 
(1) Total risk estimation using a risk estimation systemsuch as SCORE is 
recommended for asymptomatic adults>40 years of age without evidence of 
chronic cardiovascular disease (CVD), diabetes, chronic kidney disease (CKD) or familial 
hypercholesterolaemia. 
(2) High- and very high-risk individuals can be detected on the basis of 
documented CVD, diabetes mellitus,moderate to severe renal disease, very highlev- 
els of individual risk factors, familial hypercholesterolaemia or a high SCORE risk and 
are a high priority for intensive advice with regards to all risk factors. 
(3) LDL-Cholesterol (LDL-C) should be used as the primary lipid analysis for 
screening, risk estimation, diagnosis andmanagement. HDL-C is an inde- 
pendent risk factor and is included in the electronic version of SCORE,HeartScore. 
(4) LDL-Cis recommended as the primary target for treatment. 
(5) In patients at VERY HIGH CV risk, an LDL-C goal of <1.8mmol/L 
(70mg/dL), or a reduction of at least 50% if the baseline LDL-C is between 1.8 
and 3.5mmol/L (70 and 135mg/dL) is recommended. 
(6) In patients at HIGH CV risk, an LDL-C goal of <2.6mmol/L (100mg/dL), or a 
reduction of at least 50% if the baseline LDL-Ce is between 2.6 and 
5.1mmol/L (100 and 200 mg/dL) is recommended. 
(7) A statin is the usual first line treatment to reach the LDL-C goal and should be 
used up to the highest recommended dose or highest tolerable dose 
to reach the goal. 
(8) Familial Hyperlipidaemia should be suspected in patients with CHD before the 
age of 55 years for men and 60 years for women, in subjects with 
relatives with premature fatal or non-fatal CVD, in subjects with relatives having tendon 
xanthomas, and in subjects with severely elevated LDL-C 

(in adults>5mmol/L [190mg/dL], in children>4mmol/L [150mg/dL]). 
(9) Treatment with statins is recommended for older adults with established CVD 
in the 
Same way as for younger patients. 
(10) High dose statins should be given early after admission in all acute coronary 
syndrome patientswithout contraindication or a history of intolerance, 
regardless of initial LDL-C values. 
 
2.7. Total cardiovascular risk estimation (Catapano et al., 2016) 
Very high risk 
Subjects with any of the following:  
• Documented cardiovascular disease (CVD),   clinical or 
unequivocal on imaging. Documented   CVD includes previous 
myocardial infarction   (MI), acute coronary syndrome (ACS),  
coronary revascularization (percutaneous coronary intervention 
(PCI), coronary artery bypass graft surgery (CABG)) and other 
arterial revascularization procedures, stroke and transient 
ischaemic attack (TIA), and peripheral arterial disease (PAD). 
Unequivocally documented CVD on imaging is what has been 
shown to be strongly predisposed to clinical events, such as 
significant plaque on coronary angiography or carotid 
ultrasound.    
• DM with target organ damage such as proteinuria or with a 
major 
risk 
factor 
such 
as 
smoking, 
hypertension 
or 
dyslipidemia.  
• Severe CKD (GFR <30 mL/min/1.73 m2).  
• A calculated SCORE ≥10% for 10-year risk of fatal CVD. 
High risk 
Subjects with:  
• Markedly elevated single risk factors, in   particular cholesterol 
>8 
mmol/L 
(>310 
mg/dL) 
 
 
 
(e.g. 
in 
familial 
hypercholesterolaemia) or  BP ≥180/110 mmHg.  
• Most other people with DM (some young people with type 1 
diabetes may be at low or moderate risk).  
• Moderate CKD (GFR 30–59 mL/min/1.73 m2).  
• A calculated SCORE ≥5% and <10% for 10-year  risk of fatal 
CVD. 
Moderate risk 
Subjects are considered to be at moderate risk when their 
SCORE is ≥1% and <5% at 10 years.  
Low risk 
The low-risk category applies to individuals with SCORE <1% 
for 10-year risk of fatal CVD. 
 
2.8. Recommendations for lipid management in patients with moderate to severe 
chronic kidney disease (Catapano et al., 2016). 2016 ESC/EAS Guidelines for the 
Management of Dyslipidaemias  

Recommendations 
Class 
Level 
Patients with stage 3–5 CKD have to be considered 
at high or very high CV risk. 
I 
A 
The use of statins or statin/ ezetimibe combination is 
indicated in patients with non-dialysis dependent 
CKD. 
I 
A 
In patients with dialysis-dependent CKD and free of 
atherosclerotic CVD, statins should not be initiated. 
III 
A 
In patients already on statins, ezetimibe or a 
statin/ezetimibe combination at the time of dialysis 
initiation, these drugs should be continued, 
particularly in patients with CVD. 
IIb 
C 
In adult kidney transplant recipients treated with 
statins may be considered. 
IIb 
C 
 
2.9. Recommendations for treatment goals for low-density lipoprotein-cholesterol 
(Catapano et al., 2016) 
Recommendation 
Class of 
recommendation 
Level of 
evidence 
In patients at VERY HIGH CV risk, an LDL-C goal of 
<1.8 mmol/L (70 mg/dL) or a reduction of at least 50% if 
the baseline LDL-C is between 1.8 and 3.5 mmol/L (70 
and 135 mg/dL) is recommended. 
I 
B 
In patients at HIGH CV risk, an LDL-C goal of <2.6 
mmol/L (100 mg/dL), or a reduction of at least 50% if the 
baseline LDL-Ce is between 2.6 and 5.2 mmol/L (100 and 
200 mg/dL) is recommended. 
I 
B 
In subjects at LOW or MODERATE risk, an LDL-C goal 
of <3.0 mmol/L (<115 mg/dL) should be considered 
IIa 
C 
 
2.10. Lipid Measurement in Adults with CKD. (Sarnak et al., 2015). 2013 KDIGO 
Clinial Practice Guidlime for Lipid management in CKD 
1.1. In adults with newly identified CKD (including those treated with chronic 
dialysis or kidney transplantation), we recommend an evaluation with a lipid profile (total 
cholesterol, LDL cholesterol, HDL cholesterol, triglycerides). (1C) 
1.2. In adults with CKD (including those treated with chronic dialysis or kidney 
transplantation), follow-up measurement of lipid levels is not required for the majority of 
patients. (Not Graded) 
2.1.1. In adults aged ≥ 50 years with eGFR < 60 ml/min/1.73 m2 but not treated 
with chronic dialysis or kidney transplantation (GFR categories G3a-G5), we recommend 
treatment with a statin or statin/ezetimibe combination.(1A) 
2.1.2: In adults aged ≥ 50 years with CKD and eGFR ≥ 60 ml/min/1.73 m2 (GFR 
categories G1-G2), we recommend treatment with a statin. (1B) 

2.2: In adults aged 18-49 years with CKD but not treated with chronic dialysis or 
kidney transplantation, we suggest statin treatment in people with one or more of the 
following (2A): 
- known coronary disease (myocardial infarction or coronary revascularization) 
- diabetes mellitus 
- prior ischemic stroke 
- estimated 10-year incidence of coronary death or non-fatal myocardial infarction > 
10% 
2.3.1:  In adults with dialysis-dependent CKD, we suggest that statins or 
statin/ezetimibe combination not be initiated. (2A) 
2.3.2: In patients already receiving statins or statin/ezetimibe combination at the 
time of dialysis initiation, we suggest that these agents be continued. (2C) 
2.4: In adult kidney transplant recipients, we suggest treatment with a statin. (2B) 
2.11. Recommended doses of statins in adults  
Recommended doses of statins in adults 
 
ACC/AHA Recommendations 
for eGFR > 60 mL/min/1.73 m2 
KDIGO Recommendations 
for e-GFR < 60 mL/min/1.73 
m2 
High-
Intensity 
Statin 
Moderate-
Intensity Statin 
Atorvastatin 
40-80 mg 
10-20 mg 
20 mg 
Fluvastatin 
— 
80 mg 
80 mg 
Lovastatin 
— 
40 mg 
Not studied 
Pravastatin 
— 
40-80 mg 
40 mg 
Rosuvastatin 
20-40 mg 
5-10 mg 
10 mg 
Simvastatin 
—a 
20-40 mg 
40 mg 
Simvastatin/ezetimibe — 
Not mentioned in 
ACC/AHA 
guidelines 
20 mg/10 mg 
 
2.12. Simvastatin 
- Treat with statins for 1-2 weeks, up to 4-6 weeks, and maintain during long-term 
treatment. 
- Simvastatin largely excreted in the feces. Approximately 10-15% of the drug 
excreted by the kidney 
- Dosage is 5-80 mg/day, in the evening. 
- No dosage adjustment is needed in the elderly 
- Contraindications of Simvastatin:  
+ Active liver disease or unexplained persistent elevations of serum transaminases 

+ Pregnancy and lactation 
+ Concomitant administration of potent CYP3A4 inhibitors (e.g. itraconazole, 
ketoconazole, posaconazole, HIV protease inhibitors (e.g. nelfinavir), erythromycin, 
clarithromycin, telithromycin, and nefazodone) 
+ Concomitant administration of gemfibrozil, ciclosporin, or danazol. 
- Unexpected effects of Simvastatin and how to manage unexpected effects 
+ Myopathy: The risk of myopathy is related to dose. In a clinical trial of 41,413 
patients treated with simvastatin, 24,747 patients (about 60%) with an average follow-up 
of at least 4 years, the incidence of myopathy was approximately 0.03%, 0.08% and 0, 
61% at doses of 20, 40 and 80 mg/day, respectively. 
If the patients have muscle aches, weakness or cramps, do CK test. If CK increases 
(> 5 times) discontinue treatment, re-assess levels within 5 to 7 days. 
If the muscular symptoms are severe and cause daily discomfort, even if the CK 
levels are <5 times normal, consider stopping treatment. 
+ Elevated liver enzymes: Continuous elevations (up to> 3 times) liver enzymes 
have occurred in some patients receiving simvastatin. 
When simvastatin is discontinued, the level of transaminase usually decreases 
gradually down to the pre-treatment level. 
+ Diabetes Mellitus 
Some evidence suggests that statins as a class raise blood glucose and in some 
patients, at high risk of future diabetes, may produce a level of hyperglycemia where 
formal diabetes care is appropriate. This risk, however, is outweighed by the reduction in 
vascular risk with statins and therefore should not be a reason for stopping statin 
treatment.  
+ Other side effects: Dizziness, fainting, fast or irregular heartbeat,… 
2.13. Ezetimibe 
- Ezetimibe inhibits the intestinal absorption of cholesterol, which reduces 
cholesterol from the small intestine into the liver. 
- Dose may be 10-40mg / day 
- Ezetimibe is metabolized mainly in the small intestine and liver, excreted in the 
bile. 
- No dosage adjustment in elderly patients, patients with CKD 
- Hepatic impairment: EZE is not known in patients with moderate or severe liver 
failure, should not be used. 
- Patients with chronic kidney disease / renal disease 
+ Monotherapy: No need to adjust the dose of Ezetimibe. 
  
+ Combination with Simvastatin: 
 No dose adjustment of Ezetimibe or simvastatin in patients with GFR 
≥60mL/min /1.73m2. 
 In patients with GFR <60mL / min / 1.73m2), the dose of Ezetimibe is 10 
mg and simvastatin is 20 mg once daily, taken in the evening. Patients 
should be monitored if higher doses of simvastatin are used. 

2.14. New York Heart Association class III (McMurray et al., 2012) 
Classification of heart failure symptoms 
Class I 
People whose physical activity is not limited. Ordinary physical 
activity does not cause undue fatigue, heart palpitations, trouble 
breathing, or chest pain. 
Class II 
People who have some limitation on physical activity. They are 
comfortable at rest, but ordinary physical activity causes fatigue, 
heart palpitations, trouble breathing, or chest pain. 
Class III 
People who have a marked limitation on physical activity. They are 
comfortable at rest, but less-than-ordinary physical activity 
causes fatigue, heart palpitations, trouble breathing, or chest pain. 
Class IV 
People who are unable to carry on any physical activity without 
discomfort. Symptoms may be present even at rest. If any physical 
activity is done, discomfort increases. 
2.15. 2017 Taiwan lipid guidelines for high-risk patients 
LDL-C increased CV risk in patients with CKD. In adults with glomerular 
filtration rate (GFR) < 60 mL/min/1.73m2 without chronic dialysis (CKD stage 3-5), 
statin therapy should be initiated if LDL-C >/= 100 mg/dL. Ezetimibe can be added to a 
statin to consolidate the CV protection in CKD patients (Li et al., 2017) 
3. Objective of the research 
The target of this study is to focus on mechanisms underlying dyslipidemia 
in CKD and clinical trial evidence for lipid lowering therapy in patients with CKD via 
parameters of lipid, oxidative stress, tryptophan delegation as well as renal function, in 
comparison to statin/ezetimibe therapies in CKD patients with dyslipidemia. 
1) To verify the effect of lipid lowering therapies on lipid profile and inflammatory 
status in Vietnamese CKD population. [Time Frame: at the baseline and at 4th 
month, and one-year following]. 
2) To compare the effect of lipid-lowering regimes (simvastatin mono-therapy and 
EZE/simvastatin 10/20, EZE /simvastatin 10/40 combination therapy) on lipid 
profile, oxidative stress indices, Tryptophan degradation, renal parameter, and side 
effect in Vietnamese CKD patient. [Time Frame: after the 4th month, 8th month 
and one-year following]. 
 
We hope with scientific evidence, doctors will well understand the mechanism, 
effect, and safety of potential and existing therapies. Therefore, the prescription rate of 
lipid-lowering drugs and control rate of hyperlipidemia could be increased in CKD 

patients. The major purpose is to improve clinical outcomes of CKD patients through the 
control of hyperlipidemia. 
4. METHODOLOGY 
4.1. Study design: A prospectively study with clinical trials, 12 months follow up. 
4.2. Subject: 30 patients with hypercholesterolemia (LDL-C), stage 3-4 Chronic Kidney 
Disease,  not receiving dialysis and 30 control participants (sex, age-matched)  
4.2.1. Inclusion Criteria:  
30 patients with following criteria 
- CKD in the 3,4 stage (e-GFR: 15-60 ml/min/1.73 m2) 
- Presence of proteinuric CKD defined as creatinine clearance >20 ml/min/1.73 m2 
combined with urinary protein excretion rate >0.3 g/24 h 
- LDL cholesterol concentration > 100 mg/dl (2,59 mmol/l) 
- Age:  
+ ≥ 50 years old but not treated with chronic dialysis or kidney transplantation 
+ In adults aged 18-49 years with CKD but not treated with chronic dialysis or 
kidney transplantation, we suggest statin treatment in people with one or more of 
the following: 
o known coronary disease (myocardial infarction or coronary 
revascularization) 
o diabetes mellitus 
o  prior ischemic stroke 
o estimated 10-year incidence of coronary death or non-fatal 
myocardial infarction > 10% 
4.2.2. Exclusion Criteria 
- In adults with dialysis-dependent CKD 
- Heart failure (New York Heart Association class III or more) 
- Previous or concomitant treatment with corticoids, statin, immunosuppressive 
agents, vitamin B6, B12, folate 
- Pregnancy 
- Patients who do not agree to participate the research 
- Patients are unable to fully understand the purposes/risks of the study and to 
provide a written informed consent 
4.2.3. Criteria for control 
- 30 aged, sex-matched subject 
- Do not have history of diabetes, hypertension, cardiovascular or cerebrovascular 
disease, renal failure, blood dyscrasias, cancer, retinal vascular disorders 
- Current medication with vitamin B6, B12, or folic acid 
4.3. Place:  
- In Viet Nam: Internal examination room, internal department, Department of 
Biochemistry of Hue University Hospital. 
- In Italy: Department of Biochemistry of Sassari University Hospital 

4.4. Time: 3 years (From November 2017 to November 2020) 
4.5. Medication:  
- Group1: simvastatin 40mg/day 12 months 
- Group2: EZE/simvastatin (10/20) mg/day 12 months 
- Group3: EZE/simvastatin (10/40) mg/day 12 months 
4.6. Procedure 
- Potentially eligible patients attended a screening visit in an internal examination 
room or internal department of Hue University Hospital for medical history and other 
eligibility criteria checked. 
- Fasting blood samples will be taken for local laboratory assays lipid profile, 
proteinuria, urea and creatinine, creatine kinase, SGOT, SGPT, total blood count, total 
haemostasis test 
- If the patient satisfies the including criteria, written informed consent obtained 
30 enrolled patients will be randomized into 3 groups and will receive one of 3 lipid-
lowering therapies at the baseline and continue for 12 months 
Group 1:  (10 participants) receive 40 mg/day simvastatin (patient No 1, 4, 7…) 
Group 2: (10 participants) receive ezetimibe/simvastatin 10/20 mg/day: (patient No 
2, 5, 8…) 
Group 3: (10 participants) receive ezetimibe/simvastatin 10/40 mg/day: 10/40:  
(patient No 3, 6, 9…) 
- Patients will follow the treatment for 12 months and will be seen in the study 
clinics for routine follow-up checks and blood test at 4, 8, and 12 months.  
- At each follow-up time, study treatment will be continued, unexplained muscle 
pain and non-study treatment recorded. 
Patients are asked for an unscheduled visit if they want to have any additional review. 
- If patients are unable or unwilling to attend the follow-up checks, ask them if 
they have any serious adverse events. 
- The blood samples will be sent to Biochemical Department of Sassari University 
for oxidative stress indices and Tryptophan degradation indices every 4 months. 
5. Biochemical analysis 
- Serum Creatinine, GFR, urine protein, lipid profile, SGOT, SGPT, CK (Total 
Cholesterol, LDL-C, HDL-C, TG): Will be done in Hue University hospital/Hue Central 
Hospital. 
+ Total Cholesterol, LDL-C, HDL-C, and TG were measured by enzymatic 
methods using commercial kits (Boehringer-Mannheim, Mannheim, Germany): Patients 
must fast for at least 12 hours before the test  
+ Serum CK levels were measured by using a fully automated biochemical 
analyzer (Abbot). 
+ Proteinuria 
+ Serum urea, creatinine 
+ Total cells blood count 
+ Total hemostasis test 
[Time Frame: at baseline and 4, 8, 12 months of treatment] 

- Serum concentrations of Oxidative stress indices (MDA, All/UA, Taurine), Trp 
degradation indices (Kyn, Trp, Kyn/Trp ratio): Will be done in Sassari University 
hospital. 
MDA, All/UA ratio, taurine, Kyn, Trp were determined by capillary 
electrophoresis UV detection. 
Blood samples for Oxidative stress indices and Trp degradation indices will be 
collected, frozen, and sent to Sassari University hospital. 
[Time Frame: at baseline and 4, 8, 12 months of treatment] 
 
- Total Genome DNA-Methylation 
 
7. Refferences 
Catapano, A. L., Graham, I., De Backer, G., Wiklund, O., Chapman, M. J., Drexel, H., . . . Group, E. S. C. S. D. (2016). 
2016 ESC/EAS Guidelines for the Management of Dyslipidaemias. Eur Heart J, 37(39), 2999-3058. doi: 
10.1093/eurheartj/ehw272 
<CKD machenism.pdf>.  
Health, N. I. o. (2012). Kidney disease statistics for the United States. Washington: NHI.  
Hocher, B., & Adamski, J. (2017). Metabolomics for clinical use and research in chronic kidney disease. Nat Rev 
Nephrol, 13(5), 269-284. doi: 10.1038/nrneph.2017.30 
Ito, J., Dung, D. T., Vuong, M. T., Tuyen do, G., Vinh le, D., Huong, N. T., . . . Shirakawa, T. (2008). Impact and 
perspective on chronic kidney disease in an Asian developing country: a large-scale survey in North 
Vietnam. Nephron Clin Pract, 109(1), c25-32. doi: 10.1159/000134379 
Li, Y. H., Ueng, K. C., Jeng, J. S., Charng, M. J., Lin, T. H., Chien, K. L., . . . Yeh, H. I. (2017). 2017 Taiwan lipid 
guidelines for high risk patients. J Formos Med Assoc, 116(4), 217-248. doi: 10.1016/j.jfma.2016.11.013 
McMurray, J. J., Adamopoulos, S., Anker, S. D., Auricchio, A., Böhm, M., Dickstein, K., . . . Gomez‐Sanchez, M. A. 
(2012). ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. European 
journal of heart failure, 14(8), 803-869.  
Meenakshi Sundaram, S. P., Nagarajan, S., & Manjula Devi, A. J. (2014). Chronic kidney disease—effect of oxidative 
stress. Chinese Journal of Biology, 2014.  
Moutzouri, E., Liberopoulos, E. N., Tellis, C. C., Milionis, H. J., Tselepis, A. D., & Elisaf, M. S. (2013). Comparison of 
the effect of simvastatin versus simvastatin/ezetimibe versus rosuvastatin on markers of inflammation and 
oxidative stress in subjects with hypercholesterolemia. Atherosclerosis, 231(1), 8-14. doi: 
http://dx.doi.org/10.1016/j.atherosclerosis.2013.08.013 
Ruddick, J. P., Evans, Andrew K., Nutt, David J., Lightman, Stafford L., Rook, Graham A. W., & Lowry, Christopher A. . 
http://doi.org/10.1017/. (2006). Tryptophan metabolism in the central nervous system: medical 
implications. medical implications, 8, 1e27 
Sangsawang, T., & Sriwijitkamol, A. (2015). Type of dyslipidemia and achievement of the LDL-cholesterol goal in 
chronic kidney disease patients at the University Hospital. Vasc Health Risk Manag, 11, 563-567. doi: 
10.2147/vhrm.s92461 
Sarnak, M. J., Bloom, R., Muntner, P., Rahman, M., Saland, J. M., Wilson, P. W., & Fried, L. (2015). KDOQI US 
commentary on the 2013 KDIGO Clinical Practice Guideline for Lipid Management in CKD. Am J Kidney Dis, 
65(3), 354-366. doi: 10.1053/j.ajkd.2014.10.005 
Schefold, J. C., Zeden, J.-P., Fotopoulou, C., von Haehling, S., Pschowski, R., Hasper, D., . . . Reinke, P. (2009). 
Increased indoleamine 2, 3-dioxygenase (IDO) activity and elevated serum levels of tryptophan catabolites 
in patients with chronic kidney disease: a possible link between chronic inflammation and uraemic 
symptoms. Nephrology Dialysis Transplantation, 24(6), 1901-1908.  
Stevens, P. E., Levin, A., & for the Kidney Disease: Improving Global Outcomes Chronic Kidney Disease Guideline 
Development Work Group, M. (2013). Evaluation and management of chronic kidney disease: Synopsis of 
the kidney disease: improving global outcomes 2012 clinical practice guideline. Annals of Internal 
Medicine, 158(11), 825-830. doi: 10.7326/0003-4819-158-11-201306040-00007 

'Ten Commandments' from the 2016 ESC/EAS Guidelines for the management of dyslipidaemias. (2016). Eur Heart 
J, 37(39), 2966. doi: 10.1093/eurheartj/ehw415 
Trevisan, R., Dodesini, A. R., & Lepore, G. (2006). Lipids and renal disease. Journal of the American Society of 
Nephrology, 17(4 suppl 2), S145-S147.  
Zinellu, A., Sotgia, S., Mangoni, A. A., Sanna, M., Satta, A. E., & Carru, C. (2015). Impact of cholesterol lowering 
treatment on plasma kynurenine and tryptophan concentrations in chronic kidney disease: Relationship 
with oxidative stress improvement. Nutrition, Metabolism and Cardiovascular Diseases, 25(2), 153-159. 
doi: http://dx.doi.org/10.1016/j.numecd.2014.11.004