Download PDF
Der Klinikarzt 2020; 49(03): 79-84
DOI: 10.1055/a-1100-6619
Schwerpunkt
© Georg Thieme Verlag Stuttgart · New York

Antithrombotische Therapie bei Niereninsuffizienz

Was ist zu beachten?
Mark Dominik Alscher
1   Robert-Bosch-Krankenhaus, Stuttgart
› Author Affiliations
Further Information

Publication History

Publication Date:
17 March 2020 (online)

Also available at
    Permissions and Reprints

ZUSAMMENFASSUNG

Chronische Nierenerkrankungen (CKD) nehmen weltweit zu. Derzeit haben bis zu 15 % der erwachsenen Bevölkerung eine CKD. Erkrankungen wiederum, welche einer Antikoagulation bedürfen, finden sich in dieser Gruppe gehäuft, beispielsweise ein Vorhofflimmern. Bei Hämodialysepatienten findet sich dieses bei bis zu 12 % der Patienten. Auch lässt sich für diese Kombination eine erhöhte Rate von ischämischen apoplektischen Insulten demonstrieren (um das 1,6-fache gesteigert). Eine Antikoagulation bei Vorhofflimmern bei CKD ist jedoch – insbesondere bei Dialysepatienten – umstritten. Die Studienergebnisse wiederum wurden überwiegend bei Gabe von Vitamin-K-Antagonisten (VKA) erhoben. Für neuere Antikoagulantien (NOAK) sieht die Faktenlage anders aus. Es wird deshalb heute bei Notwendigkeit zur Antikoagulation bei CKD bis Stadium G4 (entsprechend Creatinin-Clearance > 15 ml/min) die Gabe von NOAK empfohlen.

 

  • Literatur

  • 1 Group KDIGOKCW. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Intern 2013 Suppl 1-150
    PubMedGoogle Scholar
  • 2 System USRD 2017 USRDS annual data report: Epidemiology of kidney disease in the United States. In Bethesda MD. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases 2017.
    PubMedGoogle Scholar
  • 3 Roderick PJ, Atkins RJ, Smeeth L. et al CKD and mortality risk in older people: a community-based population study in the United Kingdom. Am J Kidney Dis 2009; 53: 950-960
    CrossrefPubMedGoogle Scholar
  • 4 Carrero JJ, Trevisan M, Sood MM. et al Incident Atrial Fibrillation and the Risk of Stroke in Adults with Chronic Kidney Disease: The Stockholm CREAtinine Measurements (SCREAM) Project. Clin J Am Soc Nephrol 2018; 13: 1314-1320
    CrossrefPubMedGoogle Scholar
  • 5 Zeng WT, Sun XT, Tang K. et al Risk of thromboembolic events in atrial fibrillation with chronic kidney disease. Stroke; a journal of cerebral circulation 2015; 46: 157-163
    CrossrefPubMedGoogle Scholar
  • 6 Jun M, James MT, Ma Z. et al Warfarin Initiation, Atrial Fibrillation, and Kidney Function: Comparative Effectiveness and Safety of Warfarin in Older Adults With Newly Diagnosed Atrial Fibrillation. Am J Kidney Dis 2017; 69: 734-743
    CrossrefPubMedGoogle Scholar
  • 7 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 Am Coll Cardiol 2016; 67: 2888-2899
    CrossrefPubMedGoogle Scholar
  • 8 Keskar V, McArthur E, Wald R. et al The association of anticoagulation, ischemic stroke, and hemorrhage in elderly adults with chronic kidney disease and atrial fibrillation. Kidney Int 2017; 91: 928-936
    CrossrefPubMedGoogle Scholar
  • 9 Tan J, Liu S, Segal JB. et al Warfarin use and stroke, bleeding and mortality risk in patients with end stage renal disease and atrial fibrillation: a systematic review and meta-analysis. BMC Nephrol 2016; 17: 157
    CrossrefPubMedGoogle Scholar
  • 10 Shroff GR, Stoecker R, Hart A. Non-Vitamin K-Dependent Oral Anticoagulants for Nonvalvular Atrial Fibrillation in Patients With CKD: Pragmatic Considerations for the Clinician. Am J Kidney Dis 2018; 72: 717-727
    CrossrefPubMedGoogle Scholar
  • 11 Yao X, Tangri N, Gersh BJ. et al Renal Outcomes in Anticoagulated Patients With Atrial Fibrillation. J Am Coll Cardiol 2017; 70: 2621-2632
    CrossrefPubMedGoogle Scholar
  • 12 Nigwekar SU, Ingelfinger JR, Thadhani R. et al Calciphylaxis. N Engl J Med 2018; 378: 1704-1714
    CrossrefPubMedGoogle Scholar
  • 13 Blacher J, Guerin AP, Pannier B. et al Arterial calcifications, arterial stiffness, and cardiovascular risk in end-stage renal disease. Hypertension 2001; 38: 938-942
    CrossrefPubMedGoogle Scholar
  • 14 Brodsky S, Eikelboom J, Hebert LA. Anticoagulant-Related Nephropathy. J Am Soc Nephrol 2018; 29: 2787-2793
    CrossrefPubMedGoogle Scholar
  • 15 Hohnloser SH, Steg PG, Oldgren J. et al Renal Function and Outcomes With Dabigatran Dual Antithrombotic Therapy in Atrial Fibrillation Patients After PCI. JACC Cardiovascular interventions 2019; 12: 1553-1561
    CrossrefPubMedGoogle Scholar
  • 16 Ha JT, Neuen BL, Cheng LP. et al Benefits and Harms of Oral Anticoagulant Therapy in Chronic Kidney Disease: A Systematic Review and Meta-analysis. Ann Intern Med 2019; 171: 181-189
    CrossrefPubMedGoogle Scholar
  • 17 Knuuti J, Wijns W, Saraste A. et al 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2020; 41: 407-477
    CrossrefPubMedGoogle Scholar
  • 18 Foley RN, Parfrey PS, Sarnak MJ. Epidemiology of cardiovascular disease in chronic renal disease. J Am Soc Nephrol 1998; 9: S16-23
    PubMedGoogle Scholar
  • 19 Adler AI, Stevens RJ, Manley SE. et al Development and progression of nephropathy in type 2 diabetes: the United Kingdom Prospective Diabetes Study (UKPDS 64). Kidney Int 2003; 63: 225-232
    CrossrefPubMedGoogle Scholar
  • 20 Piccini JP, Stevens SR, Chang Y. et al Renal dysfunction as a predictor of stroke and systemic embolism in patients with nonvalvular atrial fibrillation: validation of the R(2)CHADS(2) index in the ROCKET AF (Rivaroxaban Once-daily, oral, direct factor Xa inhibition Compared with vitamin K antagonism for prevention of stroke and Embolism Trial in Atrial Fibrillation) and ATRIA (AnTicoagulation and Risk factors In Atrial fibrillation) study cohorts. Circulation 2013; 127: 224-232
    CrossrefPubMedGoogle Scholar
  • 21 Winkelmayer WC, Patrick AR, Liu J. et al The increasing prevalence of atrial fibrillation among hemodialysis patients. J Am Soc Nephrol 2011; 22: 349-357
    CrossrefPubMedGoogle Scholar
  • 22 Reinecke H, Brand E, Mesters R. et al Dilemmas in the management of atrial fibrillation in chronic kidney disease. J Am Soc Nephrol 2009; 20: 705-711
    CrossrefPubMedGoogle Scholar
  • 23 Go AS, Fang MC, Udaltsova N. et al Impact of proteinuria and glomerular filtration rate on risk of thromboembolism in atrial fibrillation: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study. Circulation 2009; 119: 1363-1369
    CrossrefPubMedGoogle Scholar
  • 24 Friberg L, Benson L, Lip GY. Balancing stroke and bleeding risks in patients with atrial fibrillation and renal failure: the Swedish Atrial Fibrillation Cohort study. Eur Heart J 2015; 36: 297-306
    CrossrefPubMedGoogle Scholar
  • 25 Liu G, Long M, Hu X. et al Effectiveness and Safety of Warfarin in Dialysis Patients With Atrial Fibrillation: A Meta-Analysis of Observational Studies. Medicine (Baltimore) 2015; 94: e2233
    PubMedGoogle Scholar
  • 26 Sood MM, Larkina M, Thumma JR. et al Major bleeding events and risk stratification of antithrombotic agents in hemodialysis: results from the DOPPS. Kidney Int 2013; 84: 600-608
    CrossrefPubMedGoogle Scholar