Первый Московский государственный медицинский университет им. И.М. Сеченова Россия, 119991, Москва, ул. Трубецкая, 8 стр. 2 Распространенность фибрилляции предсердий (ФП) в популяции весьма велика и продолжает расти. По существующей в настоящее время статистике ее распространенность достигает примерно 2%, что вдвое больше, чем считалось в последнее десятилетие. Распространенность ФП у пациентов с хронической болезнью почек (ХБП) составляет от 11 до 22% (по другим данным -15-20%) и увеличивается с возрастом, значительно превосходя таковую в общей популяции среди всех возрастных групп. Абсолютное большинство пациентов с ФП нуждаются в проведении терапии антикоагулянтами для профилактики ишемического инсульта и системных тромбоэмболий. Однако при сочетании ФП с ХБП, помимо увеличения частоты инсультов и тромбоэмболических осложнений, значимо увеличивается и частота серьезных кровотече-ний, что существенно затрудняет подбор адекватной антикоагулянтной терапии в такой ситуации. Много лет антагонисты витамина К были единственными представителями класса антикоагулянтов для долгосрочной терапии при ФП. Их общеизвестные недостатки (узкое терапевтическое окно, необходимость частого лабораторного контроля, многочисленные межлекарственные и диетические взаимодействия, непредсказуе-мость фармакодинамики и фармакокинетики у отдельных пациентов) способствовали поиску новых, более удобных в использовании пре-паратов. Прямые пероральные антикоагулянты оказались проще в применении, а по результатам основных исследований не уступали или превосходили варфарин в отношении баланса эффективности и безопасности. Однако у пациентов со сниженной функцией почек они спе-циально не изучались. В настоящем обзоре литературы рассматриваются особенности современной антикоагулянтной терапии у пациентов с фибрилляцией предсердий неклапанной этиологии и ХБП. Анализируется возможность максимально безопасного применения антикоа-гулянтной терапии у пациентов со снижением клиренса креатинина.Ключевые слова: фибрилляция предсердий неклапанной этиологии, хроническая болезнь почек, варфарин, прямые пероральные анти-коагулянты, дабигатран, ривароксабан, апиксабан, атеросклероз почечных артерий. Prevalence of atrial fibrillation (AF) in population is very high and continues to grow. According to the existing statistics its prevalence reaches about 2% so it is twice more, than it was considered in the last decade. Prevalence of AF among patients with chronic kidney disease (CKD) varies from 11 to 22% (according to other data -from 15 to 20%) and increases with age, considerably surpassing that in the general population among all age groups. Vast majority of patients with AF need in treatment with anticoagulants to prevent an ischemic stroke and systemic thromboembolisms. However, in case of combination AF and CKD, in addition to increase in frequency of strokes and the thromboembolic events, also the frequency of major bleedings significantly increases that considerably complicates the choice of adequate anticoagulant therapy in such situation. Many year...
In patients with non-valvular AF and diabetic and non-diabetic CKD, the use of DOACs effectively and safely prevents thromboembolic events, irrespective of the stage of CKD. At the same time, in patients taking anticoagulants, CKD progresses more rapidly in the presence of DM than in its absence, regardless of a specific anticoagulant. Hemorrhagic complications are more common in patients with AF, DM, and CKD, which requires more frequent monitoring of their kidney function.
In recent years, both Russian and foreign authors have published many papers on anticoagulant therapy for atrial fibrillation (AF). The largest are devoted to the study of direct oral anticoagulants (DOACs), which have appeared in this field since 2009, and their comparison with vitamin K antagonists (VKAs) in terms of efficacy, safety and other important characteristics. There are far fewer studies on DOACs and their comparison with VKAs and with each other in patients with AF and reduced kidney function. Most of them are retrospective. Meanwhile, the prevalence of chronic kidney disease (CKD) in the population is very high, and doctors are faced with a problem of selecting anticoagulant therapy for these patients.Purpose. To assess the effect of VKAs and DOACs on renal function in real clinical practice in patients with AF depending on the stage of CKD.Materials and methods. A prospective single-centre non-randomized non-interventional observational study in parallel groups was conducted. The study included 92 patients with AF and CKD of 1-4 stages (S1-S4). The comparison group consisted of 35 patients with AF without concomitant CKD. The patients’ age ranged from 44 to 94 years (mean age was 72.2 ± 8.5 years). Patients of both groups received anticoagulant therapy with VKA (warfarin) or one of the registered in the Russian Federation DOACs (dabigatran, rivaroxaban, apixaban). During the observation (median was 10 months), follow-up visits were every 3 months. On visits we conducted the evaluation of effectiveness (strokes / TIA and thromboembolic complications) and safety (major and minor hemorrhagic events) of anticoagulant therapy, as well as the dynamics of kidney function (CC by Cockroft-Gault, GFR by CKD-EPI).Results. The main results are devoted to patients with AF and concomitant CKD. Significant dynamics of the kidney function depending on the anticoagulant taken (VKA or representatives of the DOACs class) were not identified. There were not any thromboembolic complications and major bleedings during the observation period. Statistically significant more minor bleedings on any dose of rivaroxaban in comparison with other anticoagulants were identified.Conclusions. In patients with AF and CKD, there was no significant effect of one or another anticoagulant on the kidney function, which is probably related to the concomitant nephroprotective therapy obtained in a large percentage of cases (ACE inhibitors / ARA, calcium antagonists, statins). Therapy with DOACs and warfarin in patients with AF and CKD for an average of 10 months of followup was effective and safe. In case of AF and CKD combination, the use of dabigatran or apixaban seems to be more preferable in relation to minor bleedings, the use of which less often leads to the development of hemorrhagic events.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.