Department of Interventional Cardiology, Cardiovascular Diseases Institute, Iasi, Romania.
University of Medicine and Pharmacy Gr. T. Popa, Iasi, Romania.
Cardiovasc Drugs Ther. 2018 Oct;32(5):463-475. doi: 10.1007/s10557-018-6824-8.
A timely pharmacoinvasive strategy consisting of thrombolytic therapy (TT) plays a pivotal role in three major scenarios: acute ischemic stroke (AIS), acute myocardial infarction (STEMI), and massive pulmonary embolism (PE). Presence of advanced chronic kidney disease (CKD) (estimated glomerular filtration rate < 30 mL/min/1.73 m2), known to disturb thrombotic/thrombolytic equilibrium, causes difficulties for clinicians in evaluating risk-benefit balance, as current guidelines do not address the relationship between TT and the advanced CKD. This narrative review aims to evaluate the most important scientific resources regarding the evidences, benefits, and risks of using thrombolytics in advanced CKD.
We searched the electronic database of PubMed for studies evaluating the relationship between renal dysfunction and TT in patients with STEMI, AIS, and massive PE. Randomized controlled trials (RCTs), observational studies including prospective or retrospective cohort studies, reviews, meta-analyses, and guidelines were included if referring to TT for one of the three scenarios in advanced CKD.
Prothrombotic conditions in CKD, associated with an increased risk of hemorrhages, can affect the safety and efficacy of TT. Concerns regarding in-hospital bleeding events and poor clinical outcomes subsequent to TT in advanced CKD continue to cause underutilization or delaying routine reperfusion therapy.
The impact of TT on the outcomes of advanced CKD patients is poorly understood to date, with scarce data available in current guidelines and conflicting results from observational studies. Until evidence-based data from RCTs will be obtained, the clinical challenge of maximizing benefits for this high-risk subgroup lays in the hands of practicing clinicians.
及时的药物侵入策略包括溶栓治疗（TT）在三个主要场景中起着关键作用：急性缺血性脑卒中（AIS）、急性心肌梗死（STEMI）和大面积肺栓塞（PE）。存在先进的慢性肾脏病（CKD）（估计肾小球滤过率<30ml/min/1.73m2），已知会扰乱血栓/溶栓平衡，这给临床医生评估风险-效益平衡带来困难，因为目前的指南没有解决 TT 与先进 CKD 之间的关系。本叙述性综述旨在评估关于使用溶栓剂在先进 CKD 中的证据、益处和风险的最重要的科学资源。
我们在 PubMed 的电子数据库中搜索了评估肾功能障碍与 STEMI、AIS 和大面积 PE 患者 TT 之间关系的研究。如果涉及到 TT 用于先进 CKD 中的三种情况之一，则包括随机对照试验（RCT）、包括前瞻性或回顾性队列研究的观察性研究、综述、荟萃分析和指南。
CKD 中的促血栓形成条件与出血风险增加有关，可能会影响 TT 的安全性和有效性。对先进 CKD 中 TT 后院内出血事件和不良临床结局的担忧继续导致常规再灌注治疗的利用率低或延迟。
迄今为止，对 TT 对先进 CKD 患者结局的影响了解甚少，当前指南中可用的数据很少，观察性研究的结果也存在冲突。在获得基于 RCT 的证据之前，为这一高风险亚组最大限度地提高效益的临床挑战在于执业临床医生。
