Department of Renal Medicine, Salford Royal Hospital and University of Manchester, Greater Manchester, United Kingdom.
Department of Interventional Cardiology, Cardiovascular Diseases Institute, Iasi, Romania.
Curr Opin Nephrol Hypertens. 2018 Nov;27(6):420-425. doi: 10.1097/MNH.0000000000000443.
Non-valvular atrial fibrillation is common in patients with severe chronic kidney disease (CKD) and historically patients have been treated with vitamin K antagonists (VKA). However, these agents have questionable efficacy and are associated with increased bleeding risk. Non-vitamin K oral anticoagulants (NOAC) have advantages over VKA in early stage CKD. In this review, we sought to establish evidence for best practice in patients with severe CKD (creatinine clearance <30 ml/min including dialysis patients) and nonvalvular atrial fibrillation.
Registry studies have shown that the relative risk of stroke in untreated atrial fibrillation in dialysis patients is lower than in patients in the general population, but VKA are associated with increased haemorrhagic stroke in this high-risk population. A large meta-analysis of dialysis patients found no benefit of VKA in reducing stroke, but an increased bleeding risk. However, studies from Scandinavia have emphasized that risk of VKA are mitigated by increasing the time in anticoagulant therapeutic range (TTR). The consensus from the Kidney Disease: Improving Global Outcomes conference on arrhythmia in CKD was that if dialysis patients required OAC for atrial fibrillation then apixaban could be considered in preference to VKA.
Best practice prophylaxis against stroke risk in dialysis patients with atrial fibrillation is still an area of uncertainty. If OAC is indicated because of high risk, then treatment options include VKA with careful attention to increased TTR, or reduced dose apixaban, which would be off label in Europe. No RCT evidence currently exists to guide therapy, but RCTS of apixaban versus VKA in dialysis patients are currently underway.
重度慢性肾脏病（CKD）患者常合并非瓣膜性心房颤动，既往临床多采用维生素 K 拮抗剂（VKA）治疗。然而，此类药物疗效并不确切，且出血风险较高。新型非维生素 K 口服抗凝剂（NOAC）在早期 CKD 患者中优于 VKA。本综述旨在为重度 CKD（包括透析患者，肾小球滤过率＜30ml/min）合并非瓣膜性心房颤动患者提供最佳治疗证据。
登记研究显示，未治疗的透析患者心房颤动发生卒中的相对风险低于普通人群，但此类高风险人群中 VKA 与出血性卒中风险增加相关。一项针对透析患者的大型荟萃分析发现，VKA 并不能降低卒中风险，但增加了出血风险。然而，来自斯堪的纳维亚的研究强调，增加抗凝治疗的目标范围时间（TTR）可降低 VKA 的风险。KDIGO 心律失常会议对 CKD 患者心律失常的共识是，如果透析患者因心房颤动需要 OAC，则可考虑使用阿哌沙班而非 VKA。
对于合并心房颤动的透析患者，预防卒中风险的最佳预防措施仍存在不确定性。如果因高风险需要 OAC，则治疗方案包括仔细关注 TTR 增加的 VKA，或使用降低剂量的阿哌沙班，但在欧洲这属于超适应证用药。目前尚无 RCT 证据指导治疗，但目前正在进行阿哌沙班与 VKA 治疗透析患者的 RCT。
