Department of Pharmacy, Brigham and Women's Hospital, Boston, Mass.
Department of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque.
Am J Med. 2017 Sep;130(9):1015-1023. doi: 10.1016/j.amjmed.2017.04.015. Epub 2017 May 11.
Renal impairment increases risk of stroke and systemic embolic events and bleeding in patients with atrial fibrillation. Direct oral anticoagulants (DOACs) have varied dependence on renal elimination, magnifying the importance of appropriate patient selection, dosing, and periodic kidney function monitoring. In randomized controlled trials of nonvalvular atrial fibrillation, DOACs were at least as effective and associated with less bleeding compared with warfarin. Each direct oral anticoagulant was associated with reduced risk of stroke and systemic embolic events and major bleeding compared with warfarin in nonvalvular atrial fibrillation patients with mild or moderate renal impairment. Renal function decrease appears less impacted by DOACs, which are associated with a better risk-benefit profile than warfarin in patients with decreasing renal function over time. Limited data address the risk-benefit profile of DOACs in patients with severe impairment or on dialysis.
肾功能损害增加了房颤患者发生中风和全身性栓塞事件及出血的风险。直接口服抗凝剂（DOACs）对肾脏清除的依赖性不同，这凸显了适当的患者选择、剂量和定期肾功能监测的重要性。在非瓣膜性房颤的随机对照试验中，与华法林相比，DOACs至少同样有效，且出血风险更低。与华法林相比，在非瓣膜性房颤且伴有轻度或中度肾功能损害的患者中，每种直接口服抗凝剂均能降低中风和全身性栓塞事件及大出血的风险。肾功能下降似乎受 DOACs 的影响较小，与华法林相比，DOACs 在肾功能随时间逐渐下降的患者中具有更好的风险效益比。有限的数据涉及 DOACs 在严重肾功能损害或透析患者中的风险效益情况。
