Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.
Department of Medicine, McGill University, Montreal, Quebec, Canada.
Semin Thromb Hemost. 2018 Jun;44(4):353-363. doi: 10.1055/s-0037-1621715. Epub 2018 Jan 10.
Patients with end-stage renal disease (ESRD) were excluded from pivotal clinical trials with oral anticoagulants. While such patients are at an increased risk of venous and arterial thromboembolism, their risk of bleeding is also elevated. It is thus of little surprise that stroke prevention with vitamin K antagonists (VKAs) in ESRD patients with atrial fibrillation is controversial, with observational evidence ranging from beneficial to harmful. This uncertainty extends to the less studied use of VKAs for venous thromboembolism in ESRD. The direct oral anticoagulants (DOACs) apixaban and rivaroxaban have now permissive labeling in the United States for atrial fibrillation in patients with ESRD; this expanded labeling has not yet occurred either in Europe or for venous thromboembolism. This review summarizes the current evidence for the pharmacology of DOACs in ESRD as well as their utilization and safety in patients with ESRD and atrial fibrillation.
终末期肾病（ESRD）患者被排除在口服抗凝药物的关键临床试验之外。虽然此类患者发生静脉和动脉血栓栓塞的风险增加，但出血风险也升高。因此，维生素 K 拮抗剂（VKA）在伴有心房颤动的 ESRD 患者中的卒中预防作用颇具争议，观察性证据的结果从有益到有害不等，这并不令人意外。这种不确定性也延伸至研究较少的 ESRD 患者中 VKA 用于静脉血栓栓塞的情况。直接口服抗凝剂（DOAC）阿哌沙班和利伐沙班现已在美国获准用于 ESRD 患者的心房颤动；这种扩大的标签在欧洲或静脉血栓栓塞方面尚未出现。这篇综述总结了 DOAC 在 ESRD 中的药理学以及它们在 ESRD 和心房颤动患者中的应用和安全性的现有证据。
