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In Reply: Dr Ravnskov and Drs Kalantar-Zadeh and Anker argue that high cholesterol levels may confer protection against infection and circulating lipopolysaccharides (ie, bacterial endotoxin) and that hypercholesterolemia should not be treated among patients receiving dialysis. Ravnskov cites the protective effects of dietary cholesterol supplementation in children with Smith-Lemli-Opitz syndrome, in whom cholesterol levels are extremely low (approximately 8-62 mg/dL [0.21-1.61 mmol/L]), as well as epidemiologic findings that low total cholesterol levels (<160 mg/dL [4.14 mmol/L]) are inversely associated with risk of infection. The latter associations in older individuals (>55 years) or patients with chronic disease could result from reverse causation. Frailty and subclinical disease can exist decades prior to a clinical event.

Clinical trials have found that treatment of hypercholesterolemia with statins reduces LDL-C levels and the risk of fatal and nonfatal cardiovascular disease (CVD) and all-cause mortality.^1-2 A recent meta-analysis of 58 trials including 147 321 participants found that . . . [Full Text of this Article]

Josef Coresh, MD, PhD
Departments of Epidemiology, Medicine and Biostatistics

Yongmei Liu, MD
Department of Epidemiology
Johns Hopkins University
Baltimore, Md

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