Oral Anticoagulant Use in Patients With Atrial Fibrillation and Chronic Kidney Disease: A Review of the Evidence With Recommendations for Australian Clinical Practice.

Autor: Hammett C; Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia. Electronic address: christopher.hammett@health.qld.gov.au., Badve SV; Department of Nephrology, St George Hospital, and Renal and Metabolic Division, The George Institute for Global Health, Sydney, NSW, Australia., Kerr PG; Department of Nephrology, Monash Medical Centre and Monash University, Melbourne, Vic, Australia., Tran HA; The Alfred Hospital & Monash University, Melbourne, Vic, Australia., Dundon BK; MonashHeart, Monash Health and Victorian Heart Institute, Monash University, Melbourne, Vic, Australia., Lo S; Liverpool Hospital, SouthWest Sydney Local Health District and University of New South Wales, Sydney, NSW, Australia., Wong A; Royal Brisbane and Women's Hospital and The University of Queensland, Brisbane, Qld, Australia., Joseph JE; St Vincent's Hospital, Sydney, NSW, Australia., Deague J; Joondalup Health Campus, Perth, WA, Australia., Perkovic V; Royal North Shore Hospital and The George Institute for Global Health, Sydney, NSW, Australia.
Jazyk: angličtina
Zdroj: Heart, lung & circulation [Heart Lung Circ] 2022 Dec; Vol. 31 (12), pp. 1604-1611. Date of Electronic Publication: 2022 Nov 03.
DOI: 10.1016/j.hlc.2022.09.003
Abstrakt: Chronic kidney disease is common in patients with atrial fibrillation (AF) and is associated with heightened risks of stroke/systemic embolisation and bleeding. In this review we outline the evidence for AF stroke prevention in kidney disease, identify current knowledge gaps, and give recommendations for anticoagulation at various stages of chronic kidney disease. Overall, anticoagulation is underused. Warfarin use becomes increasingly difficult with advancing kidney disease, with difficulty maintaining international normalised ratio (INR) in therapeutic range, increased risk of intracranial and fatal bleeding compared to non-vitamin K oral anticoagulants (NOACs), and high rates of discontinuation. Similarly, the direct thrombin inhibitor dabigatran is not recommended as it is predominantly renally excreted with consequent increased plasma levels and bleeding risk with advanced kidney disease. The Factor Xa inhibitors apixaban and rivaroxaban have less renal excretion (25-35%), modest increases in plasma levels with advancing kidney disease, and are the preferred first line choice for anticoagulation in moderate kidney disease based on strong evidence from randomised clinical trials (RCTs). In severe kidney disease there is a paucity of RCT data, but extrapolation of the pharmacokinetic and RCT data for moderate kidney disease, and observational studies, support the considered use of dose-adjusted Factor Xa inhibitors unless the bleeding risk is prohibitive. In Australia, apixaban is approved for creatinine clearance down to 25 mL/min, and rivaroxaban down to 15 mL/min. For end-stage kidney disease warfarin is the only agent approved, but we recommend against anticoagulation (except in selected cases) due to high bleeding risk, multiple co-morbidities, and questionable benefit.
(Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.)
Databáze: MEDLINE
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