Department of Nephrology and Dialysis, L. Parodi - Delfino Hospital, Colleferro, Italy.
Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy.
Cardiorenal Med. 2022;12(4):131-140. doi: 10.1159/000525387. Epub 2022 Jun 7.
The frequent coexistence in daily clinical practice of chronic kidney disease (CKD) and atrial fibrillation (AF), especially in the elderly, represents a conundrum for physicians, mainly related to the management of anticoagulant therapy. The reduction of estimated glomerular filtration rate (eGFR) impairs anticoagulant clearance, increasing bleeding propensity. Moreover, dysfunctional responses of endothelial cells and inflammatory systems both trigger thromboembolic status. Those mechanisms pose an increased risk of adverse events for AF patients with CKD. While several data suggested the use of direct oral anticoagulants (DOACs) over warfarin as preferred anticoagulant strategy in patients with Stage 3A to Stage 4 CKD (eGFR range of 15-49 mL/min/1.73 m2), less is known about the optimal anticoagulation management in patients with end-stage renal disease (ESRD) or on renal replacement therapy (RRT). Furthermore, a pivotal feature to be considered when choosing the anticoagulant drug in CKD patients is represented by nephroprotective capability. Indeed, anticoagulant therapy with warfarin showed detrimental effects on kidney function, whereas DOACs demonstrated a beneficial effect on renal function preservation. Mounting data showed that, when pharmacological treatment cannot be pursued due to contraindication to anticoagulation, left atrial appendage occlusion (LAAO) may represent a valid alternative. This brief review outlines the current knowledge regarding anticoagulation therapy in ESRD/RRT patients, reporting new lines of evidence on the nephroprotective effect of oral anticoagulants and on the use of LAAO as a non-pharmacological alternative to oral anticoagulation.
在日常临床实践中，慢性肾脏病（CKD）和心房颤动（AF）经常同时存在，尤其是在老年人中，这对医生来说是一个难题，主要与抗凝治疗的管理有关。估计肾小球滤过率（eGFR）的降低会损害抗凝剂的清除率，增加出血倾向。此外，内皮细胞和炎症系统的功能障碍反应都会引发血栓栓塞状态。这些机制使 CKD 患者发生 AF 的不良事件风险增加。虽然有几项数据表明，在 3A 期至 4 期 CKD（eGFR 范围为 15-49 mL/min/1.73 m2）患者中，与华法林相比，直接口服抗凝剂（DOACs）作为首选抗凝策略，但对于终末期肾病（ESRD）或接受肾脏替代治疗（RRT）的患者，最佳抗凝管理知之甚少。此外，在选择 CKD 患者的抗凝药物时，需要考虑一个关键特征，即肾脏保护能力。事实上，华法林抗凝治疗对肾功能有不利影响，而 DOACs 则对肾功能保护有有益影响。越来越多的数据表明，由于抗凝治疗的禁忌，当无法进行药物治疗时，左心耳封堵术（LAAO）可能是一种有效的替代方法。这篇简要综述概述了 ESRD/RRT 患者抗凝治疗的当前知识，报告了口服抗凝剂的肾脏保护作用以及 LAAO 作为口服抗凝剂替代方法的新证据。
