Fish oil supplements in patients with chronic kidney disease

Cardiovascular disease (CVD) accounts for most of the increased morbidity and mortality associated with in chronic kidney disease (CKD). Cardiovascular risk emerges early in CKD, initially driven by atherosclerotic events but later dominated by heart failure and sudden cardiac death. This transition reflects progressive arteriosclerosis and the development of CKD-associated cardiomyopathy. Although patients receiving dialysis experience the highest cardiovascular risk, established atherosclerotic therapies such as lipid-lowering agents offer limited benefit at this stage. Recent therapeutic advances, including SGLT2 inhibitors, GLP1 receptor agonists and mineralocorticoid receptor antagonists, have improved outcomes in non-dialysis CKD, but the high cardiovascular mortality of dialysis patients remains largely unchanged, with multiple interventions having failed to demonstrate benefit. In this review, we outline the pleiotropic actions of omega-3 polyunsaturated fatty acids (PUFA) including anti-inflammatory, anti-oxidative, anti-thrombotic, plaque stabilising and membrane modulating effects. We discuss the PISCES trial that reported large reductions in cardiovascular events with high dose fish oil supplementation (1.6 g EPA + 0.8 g DHA daily) in 1228 haemodialysis patients followed up for 3.5 years. This treatment lowered events comprising the primary endpoint by 43% with similar reductions observed in cardiac death, myocardial infarction and stroke. Prior studies of fish oils in CKD have been small and inconclusive, underscoring the need for further large, randomised trials to confirm efficacy. If validated, omega-3 PUFA therapy could represent a long-needed advance for improving cardiovascular outcomes in haemodialysis patients.