Franczyk Beata, Gluba-Brzózka Anna, Ciałkowska-Rysz Aleksandra, Banach Maciej, Rysz Jacek
Department of Nephrology, Hypertension and Family Medicine, WAM University Hospital of Lodz, Zeromskiego 113, 90-549 Lodz, Poland.
Curr Vasc Pharmacol. 2016;14(3):260-5. doi: 10.2174/1570161114666160115130836.
Chronic kidney disease (CKD) is associated with the risk of multiple life-threatening complications such as: progression to chronic renal failure and cardiovascular disease including coronary heart disease, heart failure and peripheral arterial disease. Also, atrial fibrillation (AF) is common in this group of patients. Factors contributing to the occurrence of AF in patients undergoing dialysis include: age, presence of coronary heart disease, echocardiographic abnormalities (low ejection fraction, atrial enlargement, valvular calcification, left ventricular hypertrophy), heart failure, chronic obstructive pulmonary disease, hypertension, stroke, malnutrition (low levels of albumin, total cholesterol and high-density lipoprotein (HDL), secondary hyperparathyroidism, low predialysis systolic blood pressure, duration of renal replacement therapy as well as the method of renal replacement therapy (more frequent in haemodialysis patients). The optimal management of thromboprophylaxis in patients with CKD and AF is complex due to the fact that in patients with CKD many physiologic mechanisms are altered which lead to substantial changes in haemostasis and thus this group of patients is characterized by an increased risk of thrombotic and haemorrhagic complications. Recommendations concerning the treatment of patients with AF do not include guidelines on how to manage patients with advanced CKD, due to the lack of large randomized trials assessing the efficacy and benefits of drugs in these patients. Patients with CKD and permanent, persistent, and paroxysmal AF ought to be treated as a group with high risk of bleeding and ischaemic stroke. In case of patients with no or only one moderate risk factors, it seems that anticoagulation with antiplatelet drugs can be considered as efficient therapy, while in patients with ≥2 risk factors an oral anticoagulation therapy may be used. During long-term treatment, the international normalized ratio (INR) must be controlled at least every 14 days and adjusted within a target range of 2.0-2.5. Moreover, renal function should be evaluated before initiation of direct thrombin or factor Xa inhibitors and re-evaluated when clinically indicated and at least annually.
慢性肾脏病（CKD）与多种危及生命的并发症风险相关，例如：进展为慢性肾衰竭以及心血管疾病，包括冠心病、心力衰竭和外周动脉疾病。此外，心房颤动（AF）在这类患者中很常见。导致透析患者发生AF的因素包括：年龄、冠心病的存在、超声心动图异常（射血分数低、心房扩大、瓣膜钙化、左心室肥厚）、心力衰竭、慢性阻塞性肺疾病、高血压、中风、营养不良（白蛋白、总胆固醇和高密度脂蛋白（HDL）水平低）、继发性甲状旁腺功能亢进、透析前收缩压低、肾脏替代治疗的持续时间以及肾脏替代治疗的方法（血液透析患者更常见）。CKD和AF患者的血栓预防最佳管理很复杂，因为CKD患者的许多生理机制发生改变，这导致止血发生实质性变化，因此这类患者的血栓形成和出血并发症风险增加。由于缺乏评估药物在这些患者中的疗效和益处的大型随机试验，关于AF患者治疗的建议不包括如何管理晚期CKD患者的指南。CKD和永久性、持续性和阵发性AF患者应被视为出血和缺血性中风高风险人群。对于没有或只有一个中度风险因素的患者，似乎抗血小板药物抗凝可被视为有效治疗，而对于有≥2个风险因素的患者，可使用口服抗凝治疗。在长期治疗期间，国际标准化比值（INR）必须至少每14天控制一次，并调整至2.0 - 2.5的目标范围内。此外，在开始使用直接凝血酶或Xa因子抑制剂之前应评估肾功能，并在临床指征出现时以及至少每年重新评估一次。
