Vio Riccardo, Proietti Riccardo, Rigato Matteo, Calò Lorenzo Arcangelo
Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy.
Department of Medicine, Nephrology, Dialysis and Transplantation Unit, University of Padova, 35128 Padova, Italy.
Pharmaceuticals (Basel). 2021 Mar 19;14(3):279. doi: 10.3390/ph14030279.
Atrial fibrillation (AF) often coexists with chronic kidney disease (CKD), which confer to the patient a higher risk of both thromboembolic and hemorrhagic events. Oral anticoagulation therapy, nowadays preferably with direct oral anticoagulants (DOACs), represents the cornerstone for ischemic stroke prevention in high-risk patients. However, all four available DOACs (dabigatran, apixaban, rivaroxaban and edoxaban) are eliminated by the kidneys to some extent. Reduced kidney function facilitates DOACs accumulation and, therefore, different dose reductions are required, with slight differences between American and European recommendations especially in case of severe renal impairment (creatinine clearance < 30 mL/min). Overall, the use of DOACs in patients with non-end stage CKD and AF is effective similarly to warfarin, showing a better safety profile. The management of thromboembolic risk among patients with AF on dialysis remains challenging, as warfarin effectiveness for stroke prevention in this population is questionable and retrospective data on apixaban need to be confirmed on a larger scale. In kidney transplant recipients, DOACs may provide a potentially safer option compared to warfarin, but co-administration with immunosuppressants is a matter of concern.
心房颤动（AF）常与慢性肾脏病（CKD）并存，这使患者发生血栓栓塞和出血事件的风险更高。口服抗凝治疗，如今优选直接口服抗凝剂（DOACs），是高危患者预防缺血性卒中的基石。然而，所有四种可用的DOACs（达比加群、阿哌沙班、利伐沙班和依度沙班）在一定程度上都通过肾脏排泄。肾功能降低会促使DOACs蓄积，因此需要不同程度地减少剂量，美国和欧洲的建议略有差异，尤其是在严重肾功能损害（肌酐清除率<30 mL/分钟）的情况下。总体而言，在非终末期CKD和AF患者中使用DOACs与华法林同样有效，且安全性更好。对于接受透析的AF患者，血栓栓塞风险的管理仍然具有挑战性，因为华法林在该人群中预防卒中的有效性存疑，阿哌沙班的回顾性数据需要更大规模的验证。在肾移植受者中，与华法林相比，DOACs可能提供一个潜在更安全的选择，但与免疫抑制剂的联合使用是一个值得关注的问题。
