留言板

尊敬的读者、作者、审稿人, 关于本刊的投稿、审稿、编辑和出版的任何问题, 您可以本页添加留言。我们将尽快给您答复。谢谢您的支持!

姓名
邮箱
手机号码
标题
留言内容
验证码

口服抗凝剂在非瓣膜性房颤伴慢性肾功能不全患者中的应用进展

李欣 刘璐 柳志红 赵智慧 罗勤 赵青

李欣, 刘璐, 柳志红, 赵智慧, 罗勤, 赵青. 口服抗凝剂在非瓣膜性房颤伴慢性肾功能不全患者中的应用进展[J]. 协和医学杂志, 2022, 13(2): 302-307. doi: 10.12290/xhyxzz.2021-0256
引用本文: 李欣, 刘璐, 柳志红, 赵智慧, 罗勤, 赵青. 口服抗凝剂在非瓣膜性房颤伴慢性肾功能不全患者中的应用进展[J]. 协和医学杂志, 2022, 13(2): 302-307. doi: 10.12290/xhyxzz.2021-0256
LI Xin, LIU Lu, LIU Zhihong, ZHAO Zhihui, LUO Qin, ZHAO Qing. Progress in the Application of Oral Anticoagulants in Patients with Non-valvular Atrial Fibrillation and Chronic Renal Insufficiency[J]. Medical Journal of Peking Union Medical College Hospital, 2022, 13(2): 302-307. doi: 10.12290/xhyxzz.2021-0256
Citation: LI Xin, LIU Lu, LIU Zhihong, ZHAO Zhihui, LUO Qin, ZHAO Qing. Progress in the Application of Oral Anticoagulants in Patients with Non-valvular Atrial Fibrillation and Chronic Renal Insufficiency[J]. Medical Journal of Peking Union Medical College Hospital, 2022, 13(2): 302-307. doi: 10.12290/xhyxzz.2021-0256

口服抗凝剂在非瓣膜性房颤伴慢性肾功能不全患者中的应用进展

doi: 10.12290/xhyxzz.2021-0256
基金项目: 

北京市自然科学基金 7202168

中国医学科学院医学与健康科技创新工程 2020-I2M-C&T-B-055

详细信息
    通讯作者:

    柳志红, E-mail: zhihongliufuwai@163.com

  • 中图分类号: R541.7;R973+.2

Progress in the Application of Oral Anticoagulants in Patients with Non-valvular Atrial Fibrillation and Chronic Renal Insufficiency

Funds: 

Beijing Municipal Natural Science Foundation 7202168

CAMS Innovation Fund for Medical Sciences 2020-I2M-C&T-B-055

More Information
  • 摘要: 口服抗凝剂可有效降低房颤患者的卒中风险, 但房颤伴慢性肾功能不全患者的卒中和出血风险却明显升高, 给抗凝治疗带来困难。非维生素K拮抗剂类口服抗凝剂疗效和安全性不劣于传统的抗凝剂华法林, 无需定期监测国际标准化比值, 患者依从性更好。然而, 非维生素K拮抗剂类口服抗凝剂均不同程度地通过肾脏代谢, 其在非瓣膜性房颤伴慢性肾功能不全患者中的应用尚存在争议。本文对非瓣膜性房颤伴慢性肾功能不全患者口服抗凝剂的应用进展进行综述, 以期为临床实践提供参考。
    作者贡献:李欣负责资料收集、初稿撰写;刘璐、罗勤、赵青负责论文修订;柳志红、赵智慧负责论文审校。
    利益冲突:所有作者均声明不存在利益冲突
  • 表  1  临床常用口服抗凝药物特征比较

    项目 华法林 达比加群酯 利伐沙班 阿哌沙班 依度沙班
    机制 维生素K拮抗剂 直接凝血酶拮抗剂 凝血因子Ⅹa拮抗剂 凝血因子Ⅹa拮抗剂 凝血因子Ⅹa拮抗剂
    代谢 99%肝脏 80%肾脏 33%肾脏 27%肾脏 50%肾脏
    血浆蛋白结合率 99% 35% 95% 87% 55%
    透析清除率 <1% 50%~60% <1% 6% 9%
    FDA批准可应用的CrCl阈值[5](mL/min) 15 15 15
    相较于华法林卒中的风险比[5](95% CI) 参照 0.56(0.37~0.85) 0.88(0.65~1.19) 0.79(0.55~1.14) 0.87(0.65~1.18)
    相较于华法林大出血的风险比[5](95% CI) 参照 1.01(0.79~1.30) 0.98(0.84~1.14) 0.50(0.38~0.66) 0.76(0.58~0.98)
    FDA:美国食品药品监督管理局;CrCl:肌酐清除率
    下载: 导出CSV
  • [1] Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)[J]. Eur Heart J, 2021, 42: 373-498.
    [2] Staerk L, Wang B, Preis SR, et al. Lifetime risk of atrial fibrillation according to optimal, borderline, or elevated levels of risk factors: cohort study based on longitudinal data from the Framingham Heart Study[J]. BMJ, 2018, 361: k1453.
    [3] Hart RG, Eikelboom JW, Brimble KS, et al. Stroke Prevention in Atrial Fibrillation Patients With Chronic Kidney Disease[J]. Can J Cardiol, 2013, 29: S71-S78. doi:  10.1016/j.cjca.2013.04.005
    [4] Banerjee A, Fauchier L, Vourc'h P, et al. A Prospective Study of Estimated Glomerular Filtration Rate and Outcomes in Patients With Atrial Fibrillation: The Loire Valley Atrial Fibrillation Project[J]. Chest, 2014, 145: 1370-1382. doi:  10.1378/chest.13-2103
    [5] Chan KE, Giugliano RP, Patel MR, et al. Nonvitamin K Anticoagulant Agents in Patients With Advanced Chronic Kidney Disease or on Dialysis With AF[J]. J Am Coll Cardiol, 2016, 67: 2888-2899. doi:  10.1016/j.jacc.2016.02.082
    [6] Writing Group Members, January CT, Wann LS, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society[J]. Heart Rhythm, 2019, 16: e66-e93. doi:  10.1016/j.hrthm.2019.01.024
    [7] Granger CB, Alexander JH, McMurray JJ, et al. Apixaban versus warfarin in patients with atrial fibrillation[J]. N Engl J Med, 2011, 365: 981-992. doi:  10.1056/NEJMoa1107039
    [8] Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation[J]. N Engl J Med, 2011, 365: 883-891. doi:  10.1056/NEJMoa1009638
    [9] Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation[J]. N Engl J Med, 2009, 361: 1139-1151. doi:  10.1056/NEJMoa0905561
    [10] Giugliano RP, Ruff CT, Braunwald E, et al. Edoxaban versus warfarin in patients with atrial fibrillation[J]. N Engl J Med, 2013, 369: 2093-2104. doi:  10.1056/NEJMoa1310907
    [11] Toyoda K, Ninomiya T. Stroke and cerebrovascular diseases in patients with chronic kidney disease[J]. Lancet Neurol, 2014, 13: 823-833. doi:  10.1016/S1474-4422(14)70026-2
    [12] Weiner DE, Tighiouart H, Amin MG, et al. Chronic kidney disease as a risk factor for cardiovascular disease and all-cause mortality: a pooled analysis of community-based studies[J]. J Am Soc Nephrol, 2004, 15: 1307-1315. doi:  10.1097/01.ASN.0000123691.46138.E2
    [13] Lee M, Saver JL, Chang KH, et al. Low glomerular filtration rate and risk of stroke: meta-analysis[J]. BMJ, 2010, 341: c4249. doi:  10.1136/bmj.c4249
    [14] Elkin PL, Mullin S, Mardekian J, et al. Using Artificial Intelligence With Natural Language Processing to Combine Electronic Health Record's Structured and Free Text Data to Identify Nonvalvular Atrial Fibrillation to Decrease Strokes and Death: Evaluation and Case-Control Study[J]. J Med Internet Res, 2021, 23: e28946. doi:  10.2196/28946
    [15] Wattanaruengchai P, Nathisuwan S, Karaketklang K, et al. Comparison of the HAS-BLED versus ORBIT Scores in Predicting Major Bleeding Among Asians Receiving the Direct-Acting Oral Anticoagulants[J]. Br J Clin Pharmacol, 2021. doi: 10.1111/bcp.15145.[Epub ahead of print].
    [16] Steffel J, Collins R, Antz M, et al. 2021 European Heart Rhythm Association Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation[J]. Europace, 2021, 23: 1612-1676.
    [17] Dahal K, Kunwar S, Rijal J, et al. Stroke, Major Bleeding, and Mortality Outcomes in Warfarin Users With Atrial Fibrillation and Chronic Kidney Disease: A Meta-Analysis of Observational Studies[J]. Chest, 2016, 149: 951-959. doi:  10.1378/chest.15-1719
    [18] Hart RG, Pearce LA, Asinger RW, et al. Warfarin in atrial fibrillation patients with moderate chronic kidney disease[J]. Clin J Am Soc Nephrol, 2011, 6: 2599-2604. doi:  10.2215/CJN.02400311
    [19] Ryan M, Ware K, Qamri Z, et al. Warfarin-related nephropathy is the tip of the iceberg: direct thrombin inhibitor dabigatran induces glomerular hemorrhage with acute kidney injury in rats[J]. Nephrol Dial Transplant, 2014, 29: 2228-2234. doi:  10.1093/ndt/gft380
    [20] Ware K, Brodsky P, Satoskar AA, et al. Warfarin-related nephropathy modeled by nephron reduction and excessive anticoagulation[J]. J Am Soc Nephrol, 2011, 22: 1856-1862. doi:  10.1681/ASN.2010101110
    [21] Brodsky SV, Nadasdy T, Rovin BH, et al. Warfarin-related nephropathy occurs in patients with and without chronic kidney disease and is associated with an increased mortality rate[J]. Kidney Int, 2011, 80: 181-189. doi:  10.1038/ki.2011.44
    [22] Fordyce CB, Hellkamp AS, Lokhnygina Y, et al. On-Treatment Outcomes in Patients With Worsening Renal Function With Rivaroxaban Compared With Warfarin: Insights From ROCKET AF[J]. Circulation, 2016, 134: 37-47. doi:  10.1161/CIRCULATIONAHA.116.021890
    [23] Bohula EA, Giugliano RP, Ruff CT, et al. Impact of Renal Function on Outcomes With Edoxaban in the ENGAGE AF-TIMI 48 Trial[J]. Circulation, 2016, 134: 24-36. doi:  10.1161/CIRCULATIONAHA.116.022361
    [24] Jun M, James MT, Ma Z, et al. Warfarin Initiation, Atrial Fibrillation, and Kidney Function: Comparative Effective-ness and Safety of Warfarin in Older Adults With Newly Diagnosed Atrial Fibrillation[J]. Am J Kidney Dis, 2017, 69: 734-743. doi:  10.1053/j.ajkd.2016.10.018
    [25] Stanifer JW, Pokorney SD, Chertow GM, et al. Apixaban Versus Warfarin in Patients With Atrial Fibrillation and Advanced Chronic Kidney Disease[J]. Circulation, 2020, 141: 1384-1392. doi:  10.1161/CIRCULATIONAHA.119.044059
    [26] Olesen JB, Lip GY, Kamper AL, et al. Stroke and bleeding in atrial fibrillation with chronic kidney disease[J]. N Engl J Med, 2012, 367: 625-635. doi:  10.1056/NEJMoa1105594
    [27] Kai B, Bogorad Y, Nguyen LN, et al. Warfarin use and the risk of mortality, stroke, and bleeding in hemodialysis patients with atrial fibrillation[J]. Heart Rhythm, 2017, 14: 645-651. doi:  10.1016/j.hrthm.2017.01.047
    [28] Shah M, Avgil Tsadok M, Jackevicius CA, et al. Warfarin use and the risk for stroke and bleeding in patients with atrial fibrillation undergoing dialysis[J]. Circulation, 2014, 129: 1196-1203. doi:  10.1161/CIRCULATIONAHA.113.004777
    [29] Chan KE, Lazarus JM, Thadhani R, et al. Warfarin use associates with increased risk for stroke in hemodialysis patients with atrial fibrillation[J]. J Am Soc Nephrol, 2009, 20: 2223-2233. doi:  10.1681/ASN.2009030319
    [30] Chang SH, Wu CV, Yeh YH, et al. Efficacy and Safety of Oral Anticoagulants in Patients With Atrial Fibrillation and Stages 4 or 5 Chronic Kidney Disease[J]. Am J Med, 2019, 132: 1335-1343. doi:  10.1016/j.amjmed.2019.06.006
    [31] Dahal K, Kunwar S, Rijal J, et al. Stroke, Major Bleeding, and Mortality Outcomes in Warfarin Users With Atrial Fibrillation and Chronic Kidney Disease: A Meta-Analysis of Observational Studies[J]. Chest, 2016, 149: 951-959. doi:  10.1378/chest.15-1719
    [32] Wong CX, Odutayo A, Emdin CA, et al. Meta-Analysis of Anticoagulation Use, Stroke, Thromboembolism, Bleeding, and Mortality in Patients With Atrial Fibrillation on Dialysis[J]. Am J Cardiol, 2016, 117: 1934-1941. doi:  10.1016/j.amjcard.2016.03.042
    [33] Wang X, Tirucherai G, Marbury TC, et al. Pharmacokinetics, pharmacodynamics, and safety of apixaban in subjects with end-stage renal disease on hemodialysis[J]. J Clin Pharmacol, 2016, 56: 628-636. doi:  10.1002/jcph.628
    [34] Chang M, Yu Z, Shenker A, et al. Effect of renal impair-ment on the pharmacokinetics, pharmacodynamics, and safety of apixaban[J]. J Clin Pharmacol, 2016, 56: 637-645. doi:  10.1002/jcph.633
  • 加载中
表(1)
计量
  • 文章访问数:  404
  • HTML全文浏览量:  49
  • PDF下载量:  50
  • 被引次数: 0
出版历程
  • 收稿日期:  2021-03-08
  • 录用日期:  2021-06-16
  • 网络出版日期:  2021-12-28
  • 刊出日期:  2022-03-30

目录

    /

    返回文章
    返回

    【温馨提醒】近日,《协和医学杂志》编辑部接到作者反映,有多名不法人员冒充期刊编辑发送见刊通知,鼓动作者添加微信,从而骗取版面费的行为。特提醒您,本刊与作者联系的方式均为邮件通知或电话,稿件进度通知邮箱为:mjpumch@126.com,编辑部电话为:010-69154261,请提高警惕,谨防上当受骗!如有任何疑问,请致电编辑部核实。谢谢!