2.4: In adult kidney transplant recipients, we suggest treatment with a statin. (2B) RATIONALE The risk of future coronary events in kidney transplant recipients is markedly elevated: data from the placebo arm of the ALERT trial suggest that the rate of cardiovascular death or non-fatal MI is approximately 21.5 per 1000 patient- Data on the rate of non-fatal MI by age are not available for kidney transplant recipients, but a population- based study from Australia and New Zealand suggests that the rate of cardiovascular death alone is approximately 5 per 1000 patient-years even among those aged 25 44 years.49 Data on the effect of statins in adult kidney transplant recipients are presented in Supplemental Tables 29 31 online. ALERTexamined the effect of statin therapy on cardiovascular risk reduction in 2102 patients aged 30 75 years with functioning kidney transplants who were followed for 5 6 years. Fluvastatin therapy (40 80 mg/day) led to a non- significant 17% reduction in the primary outcome of coronary death or non-fatal MI, compared to placebo (RR 0.83; 95% CI 0.64 1.06). However, fluvastatin led to a significant 35% relative reduction in the risk of cardiac death or definite non- and an unblinded extension study found that randomization to fluvastatin was associated with a significant reduction in the original primary outcome after 6.7 years of follow-up. In the judgment of the Work Group, the apparent benefits observed in ALERT are consistent with the effects of statins in the general population, and suggest that statins are beneficial in patients with a functioning kidney transplant. However, the nominal lack of statistical significance in the primary analysis and the existence of a single randomized trial favor a weak recommendation. 