Berger Martin, Baaten Constance C F M J, Noels Heidi, Marx Nikolaus, Schütt Katharina
Department of Internal Medicine I, RWTH Aachen University Hospital, Aachen, Deutschland.
Institut für Molekulare Herz-Kreislauf-Forschung (IMCAR), RWTH Aachen University, Aachen, Deutschland.
Herz. 2022 Oct;47(5):426-433. doi: 10.1007/s00059-022-05129-3. Epub 2022 Jul 21.
Patients with chronic kidney disease (CKD) have an increased risk of thrombosis and approximately 50% of patients with advanced CKD die because of a cardiovascular disease. In addition to an increased risk of thrombosis, patients with CKD and particularly with advanced CKD, have an increased risk of hemorrhage, which increases parallel to the decline of kidney function. Due to this parallel existence of the prohemorrhagic and prothrombotic phenotype, antiplatelet treatment is difficult in the daily routine and data show that CKD patients with acute coronary syndrome (ACS) are less likely to receive guideline-conform treatment. The underlying mechanisms are currently insufficiently understood and both platelet-dependent mechanisms and also platelet-independent mechanisms are under discussion. Accordingly, there is currently no specific treatment or treatment strategy for patients with CKD. In addition, CKD patients are underrepresented in registration studies on antiplatelet treatment and there are no data from randomized trials for patients with advanced CKD (CKD ≥ 4). Current guideline recommendations are therefore based on subgroup analyses and observational studies. In addition, questions on the duration of treatment, on risk scores for estimation of the risk of hemorrhage and on potential benefits of escalation and de-escalation strategies remain largely unanswered and should therefore be the focus of future studies.
慢性肾脏病（CKD）患者发生血栓形成的风险增加，约50%的晚期CKD患者死于心血管疾病。除了血栓形成风险增加外，CKD患者，尤其是晚期CKD患者，出血风险也增加，且随着肾功能下降而平行增加。由于出血倾向和血栓形成倾向这两种表型同时存在，抗血小板治疗在日常临床中存在困难，数据显示急性冠状动脉综合征（ACS）的CKD患者不太可能接受符合指南的治疗。其潜在机制目前尚未完全了解，血小板依赖性机制和非血小板依赖性机制都在讨论之中。因此，目前尚无针对CKD患者的特异性治疗方法或治疗策略。此外，在抗血小板治疗的注册研究中，CKD患者的代表性不足，并且没有针对晚期CKD（CKD≥4期）患者的随机试验数据。因此，当前的指南建议基于亚组分析和观察性研究。此外，关于治疗持续时间、出血风险评估的风险评分以及强化和降级策略的潜在益处等问题在很大程度上仍未得到解答，因此应成为未来研究的重点。
