Chronic kidney disease (CKD) is associated with a high prevalence of atrial fibrillation (AF), but in patients with severe renal impairment, the risk/benefit ratio of anticoagulant therapy with vitamin K antagonists (VKA) for thromboprophylaxis is uncertain. In end-stage renal disease (ESRD) patients undergoing hemodialysis, VKA seem less effective in stroke prevention than in the general population, with an increased risk of major bleeding. Recently, novel oral anticoagulant agents (NOACs) have proven to be effective for stroke prevention in AF and have demonstrated an improved safety profile compared with VKA. Limited data from posthoc analyses of controlled clinical trials suggest the safe and effective use of NOACs in patients with moderate renal impairment (i.e., estimated glomerular filtration rate [eGFR] between 30 and 50 mL/min). The question still remains whether NOACs can be used in patients with an eGFR less than 30 mL/min, because there are no studies addressing this subject. In fact, patients with CKD stage 4 and 5 were excluded from controlled clinical trials on anticoagulation therapy for stroke prevention in AF. Left atrial appendage (LAA) occlusion represents a nonpharmacologic alternative for stroke prevention in patients with AF who are difficult to manage medically. Preliminary data indicate a similar efficacy and safety profile in patients with CKD compared with patients with normal renal function. Stroke prevention in patients with ESRD and AF represents a clinical challenge with poor evidence. LAA occlusion may become the standard of care for stroke prevention in patients with ESRD and AF.
Ronco, F., Mazzone, P., Hosseinian, L., Genovesi, S. (2019). Recent Advances for Stroke Prevention in Patients With Atrial Fibrillation and Advanced Kidney Disease. In C. Ronco, R. Bellomo, J.A. Kellum, Z. Ricci (a cura di), Critical Care Nephrology: Third Edition (pp. 736-740.e2). Elsevier Inc. [10.1016/B978-0-323-44942-7.00120-5].
Recent Advances for Stroke Prevention in Patients With Atrial Fibrillation and Advanced Kidney Disease
Genovesi S.
2019
Abstract
Chronic kidney disease (CKD) is associated with a high prevalence of atrial fibrillation (AF), but in patients with severe renal impairment, the risk/benefit ratio of anticoagulant therapy with vitamin K antagonists (VKA) for thromboprophylaxis is uncertain. In end-stage renal disease (ESRD) patients undergoing hemodialysis, VKA seem less effective in stroke prevention than in the general population, with an increased risk of major bleeding. Recently, novel oral anticoagulant agents (NOACs) have proven to be effective for stroke prevention in AF and have demonstrated an improved safety profile compared with VKA. Limited data from posthoc analyses of controlled clinical trials suggest the safe and effective use of NOACs in patients with moderate renal impairment (i.e., estimated glomerular filtration rate [eGFR] between 30 and 50 mL/min). The question still remains whether NOACs can be used in patients with an eGFR less than 30 mL/min, because there are no studies addressing this subject. In fact, patients with CKD stage 4 and 5 were excluded from controlled clinical trials on anticoagulation therapy for stroke prevention in AF. Left atrial appendage (LAA) occlusion represents a nonpharmacologic alternative for stroke prevention in patients with AF who are difficult to manage medically. Preliminary data indicate a similar efficacy and safety profile in patients with CKD compared with patients with normal renal function. Stroke prevention in patients with ESRD and AF represents a clinical challenge with poor evidence. LAA occlusion may become the standard of care for stroke prevention in patients with ESRD and AF.I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.