Bilha Stefana Catalina, Burlacu Alexandru, Siriopol Dimitrie, Voroneanu Luminita, Covic Adrian
Department of Nephrology, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania.
Department of Interventional Cardiology, Cardiovascular Diseases Institute, Iasi, Romania.
Cerebrovasc Dis. 2018;45(1-2):33-41. doi: 10.1159/000486016. Epub 2018 Jan 9.
Although chronic kidney disease (CKD) is an independent risk factor for stroke, official recommendations for the primary prevention of stroke in CKD are generally lacking.
We searched PubMed and ISI Web of Science for randomised controlled trials, observational studies, reviews, meta-analyses and guidelines referring to measures of stroke prevention or to the treatment of stroke-associated risk factors (cardiovascular disease in general and atrial fibrillation (AF), arterial hypertension or carotid artery disease in particular) among the CKD population. The use of oral anticoagulation in AF appears safe in non-end stage CKD, but it should be individualized and preferably based on thromboembolic and bleeding stratification algorithms. Non-vitamin K antagonist oral anticoagulants with definite dose adjustment are generally preferred over vitamin K antagonists in mild and moderate CKD and their indications have started being extended to severe CKD and dialysis also. Aspirin, but not clopidogrel, has limited indications for reducing the risk for atherothrombotic events in CKD due to its increased bleeding risk. Carotid endarterectomy has shown promising results for stroke risk reduction in CKD patients with high-grade symptomatic carotid stenosis. The medical treatment of arterial hypertension in CKD often fails to efficiently lower blood pressure values, but recent data regarding the use of interventional procedures such as renal denervation, baroreflex activation therapy or renal artery stenting are encouraging. Key Messages: In the absence of clear guidelines and protocols, primary prevention of stroke in CKD patients remains a subtle art in the hands of the clinicians. Nevertheless, refraining CKD patients from standard therapies often worsens their prognosis.
尽管慢性肾脏病（CKD）是卒中的独立危险因素，但目前普遍缺乏针对CKD患者卒中一级预防的官方建议。
我们检索了PubMed和科学引文索引（ISI）Web of Science数据库，查找关于CKD人群中卒中预防措施或卒中相关危险因素（一般心血管疾病，特别是心房颤动（AF）、动脉高血压或颈动脉疾病）治疗的随机对照试验、观察性研究、综述、荟萃分析和指南。在非终末期CKD患者中，AF患者使用口服抗凝药似乎是安全的，但应个体化用药，最好基于血栓栓塞和出血分层算法。在轻度和中度CKD患者中，一般首选剂量明确可调整的非维生素K拮抗剂口服抗凝药，其适应证也已开始扩展至重度CKD和透析患者。由于出血风险增加，阿司匹林而非氯吡格雷在降低CKD患者动脉粥样硬化血栓形成事件风险方面的适应证有限。对于有高度症状性颈动脉狭窄的CKD患者，颈动脉内膜切除术在降低卒中风险方面已显示出有前景的结果。CKD患者的动脉高血压药物治疗往往难以有效降低血压值，但最近关于肾去神经支配、压力反射激活疗法或肾动脉支架置入等介入治疗应用的数据令人鼓舞。关键信息：在缺乏明确指南和方案的情况下，CKD患者的卒中一级预防在临床医生手中仍是一门微妙的艺术。然而，不让CKD患者接受标准治疗往往会使其预后恶化。
