Evidence that TLC will reduce serum TGs in patients with CKD is weak. However, the elements of TLC are unlikely to lead to harm and may improve general health. In the opinion of the Work Group, it is reasonable to advise patients with high fasting levels of serum TGs (45.65 mmol/l [4500 mg/dl]) to adopt TLC. Dietary changes that may reduce serum TGs include a low-fat diet (o15% total calories), reduction of mono- saccharide and disaccharide intake, reducing the total amount of dietary carbohydrates, and use of fish oils to replace some long-chain TGs. Dietary modification should be used judiciously, if at all, in individuals who are malnourished. This is a weak recommendation that is based on very low quality evidence. Pharmacological treatment of high triglycerides: effects on risk of pancreatitis Although previous guidelines have suggested the use of fibric acid derivatives for preventing pancreatitis from severe the evidence supporting the safety and efficacy of this approach is extremely weak, especially in patients with CKD. Therefore, the Work Group no longer recommends this approach, especially since statins appear to prevent pancreatitis in people with normal or mildly Fibric acid derivatives could be considered for the rare patients with CKD and markedly elevated fasting levels of serum TG (411.3 mmol/l [41000 mg/dl]). If such therapy is prescribed, fibric acid derivatives must be dose-adjusted for kidney function. There is limited evidence to recommend one fibric acid derivative over another in the setting of CKD and therefore any of the alternatives may be used. 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. 