Cases Aleix, Gomez Pablo, Broseta Jose Jesus, Perez Bernat Elisa, Arjona Barrionuevo Juan de Dios, Portolés Jose Maria, Gorriz Jose Luis
Departament de Medicina, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
Unidad de Factores de Riesgo Vascular, Servicio de Nefrología, Hospital Universitario de Jerez, Jerez de la Frontera, Spain.
Front Med (Lausanne). 2021 Sep 17;8:654620. doi: 10.3389/fmed.2021.654620. eCollection 2021.
Atrial fibrillation (AF) is the most common arrhythmia in chronic kidney disease (CKD), with a close bidirectional relationship between the two entities. The presence of CKD in AF increases the risk of thromboembolic events, mortality and bleeding. Vitamin K antagonists (VKA) have been the mainstay of treatment for the prevention of thromboembolic events in AF until recently, with confirmed benefits in AF patients with stage 3 CKD. However, the risk-benefit profile of VKA in patients with AF and stages 4-5 CKD is controversial due to the lack of evidence from randomized controlled trials. Treatment with VKA in CKD patients has been associated with conditions such as poorer anticoagulation quality, increased risk of bleeding, faster progression of vascular/valvular calcification and higher risk of calciphylaxis. Direct oral anticoagulants (DOACs) have shown equal or greater efficacy in stroke/systemic embolism prevention, and a better safety profile than VKA in analysis of the pivotal randomized controlled trials in patients with non-valvular AF and stage 3 CKD, yet evidence of its risk-benefit profile in more advanced stages of CKD is scarce. Observational studies associate DOACs with a good safety/effectiveness profile compared to VKA in non-dialysis CKD patients. Further, DOACs have been associated with a lower risk of acute kidney injury and CKD development/progression than VKA. This narrative review summarizes the evidence of the efficacy and safety of warfarin and DOACs in patients with AF at different CKD stages, as well as their effects on renal function, vascular/valvular calcification and bone health.
心房颤动（AF）是慢性肾脏病（CKD）中最常见的心律失常，这两种疾病之间存在密切的双向关系。AF患者合并CKD会增加血栓栓塞事件、死亡和出血的风险。直到最近，维生素K拮抗剂（VKA）一直是预防AF患者血栓栓塞事件的主要治疗药物，已证实对3期CKD的AF患者有益。然而，由于缺乏随机对照试验的证据，VKA在4-5期CKD合并AF患者中的风险效益情况存在争议。CKD患者使用VKA治疗与抗凝质量较差、出血风险增加、血管/瓣膜钙化进展加快以及钙化防御风险较高等情况相关。在非瓣膜性AF和3期CKD患者的关键随机对照试验分析中，直接口服抗凝剂（DOACs）在预防中风/全身性栓塞方面显示出同等或更高的疗效，且安全性优于VKA，但在CKD更晚期阶段其风险效益情况的证据却很少。观察性研究表明，与VKA相比，DOACs在非透析CKD患者中具有良好的安全性/有效性。此外，与VKA相比，DOACs与急性肾损伤以及CKD发生/进展的风险较低相关。本叙述性综述总结了华法林和DOACs在不同CKD阶段AF患者中的疗效和安全性证据，以及它们对肾功能、血管/瓣膜钙化和骨骼健康的影响。
