As mentioned in Chapter 2, concomitant therapy with both a fibric acid derivative and a statin is not recommended in patients with CKD due to the potential for toxicity. Nicotinic acid has not been well studied in advanced CKD and therefore is not recommended for treatment of severe hypertriglyceridemia, given the risk of toxicity (especially flushing and hyperglycemia). The Work Group considered a weak recommendation against the use of fibric acid derivatives in people with CKD. However, in the judgment of the Work Group, there is insufficient evidence to recommend for or against the use of fibric acid derivatives in this population. Treatment with fibric acid derivatives might be warranted in patients who place a relatively high value on preventing pancreatitis, and a relatively low value on the risks of polypharmacy and drug toxicity. Pharmacological treatment of high triglycerides: effects on cardiovascular risk A meta-analysis of data from 18 randomized trials involving 45,058 participants drawn from the general population (i.e., not specific to CKD) demonstrated a modest 10% RR reduction (95% CI 0 18; p 0.048) in major cardiovascular events and a 13% RR reduction in coronary events (95% CI 7 19; p o0.0001) for fibrate therapy. But such benefits are smaller than the 20% reduction in vascular events and 10% reduction in mortality demonstrated by statins per mmol/l reduction in LDL-C.14,89,90 As mentioned in Chapter 1, the dyslipidemia associated with CKD appear particularly suited to therapy with fibric acid derivatives, which alter triglyceride-rich lipoproteins more than LDL-C, the main target of statins. This observation has raised the hypothesis that fibrates might be especially effective for preventing vascular events in CKD populations. Randomized treatment trials that examined the effect of fibrates relative to placebo in patients with diabetes and CKD are summarized below. 