DOAC use in patients with chronic kidney disease

Seher Kcükköylü; Lars Christian Rump

doi:10.5482/HAMO-17-01-0003

Hämostaseologie, Table of Contents

Hamostaseologie 2017; 37(04): 286-294
DOI: 10.5482/HAMO-17-01-0003

Review

Schattauer GmbH

DOAC use in patients with chronic kidney disease

An update>DOAK bei Patienten mit chronischen NierenerkrankungenUpdate

Seher Kcükköylü

¹Department of Medicine, Division of Nephrology, University of Düsseldorf

,

Lars Christian Rump

¹Department of Medicine, Division of Nephrology, University of Düsseldorf

› Author Affiliations

Abstract

Summary

Direct oral anticoagulants (DOACs) are increasingly prescribed substances in patients with indication for effective anticoagulation. Patients with chronic kidney disease (CKD) have a high burden of cardiovascular risk and are more likely to develop atrial fibrillation (AF) than patients without CKD. Patients with mild to moderate CKD benefit from DOACs, especially when having intolerance to vitamin K-antagonists (VKA). DOACs may in some cases be considered in patients with rare renal disease and hypercoagulabilic state. DOACs are to a large extent eliminated by renal excretion. Since prospective randomised data in CKD patients are sparse, the decision for anticoagulative therapy is challenging especially in patients with severe renal impairment. The direct factor Xa-inhibitors are approved for use even in patients with an estimated glomerular filtration rate (eGFR) between 15 and 30 ml/min. Careful monitoring of renal function on a regular basis is essential before initiation and after start of DOAC, especially for patients at risk for acute renal failure (elderly, diabetics, patients with preexisting kidney disease). None of the DOACs is approved in CKD patients with end-stage-renal-disease (ESRD) with or without dialysis. DOACs are not recommended for kidney transplant patients under immunosuppression with calcineurin inhibitors. In these patients conventional therapy with VKA is the only option, which has to be monitored closely since it has potential adverse effects.

Zusammenfassung

Die direkten oralen Antikoagulantien (DOAK) werden zunehmend häufiger bei Patienten mit einer Indikation für eine effektive Antikoagulation verordnet. Im Vergleich zu Patienten ohne chronische Nierenerkrankung (CKD) haben Patienten mit CKD ein höheres kardiovaskuläres Risiko und eine höhere Wahrscheinlichkeit, Vorhofflimmern zu entwickeln. Die Behandlung mit DOAK ist bei Patienten mit milder bis mäßiger CKD von Vorteil, insbesonde-re wenn eine Unverträglichkeit gegen Vitamin-K-Antagonisten (VKA) besteht. DOAK können in Einzelfällen auch bei Patienten mit seltenen Nierenerkrankungen und Hyperkoagulabilität eingesetzt werden. Die DOAK werden zu einem großen Teil renal eliminiert. Da prospektive, randomisierte Daten zu CKD-Patienten rar sind, ist die Entscheidung für eine Antikoagulation schwierig, insbesondere bei Patienten mit deutlich eingeschränkter Nierenfunktion. Die direkten Faktor-Xa-Hemmer sind auch bei Patienten mit einer geschätzten glomerulären Filtrationsrate (GFR) von 15 bis 30 ml/min zugelassen. Es ist jedoch notwendig, die Nierenfunktion vor und nach Beginn der DOAK sorgfältig und regelmäßig zu evaluieren, besonders bei Patienten mit einem höheren Risiko für ein akutes Nierenversagen (Ältere, Diabetiker, Patienten mit bekannter Nierenerkrankung). Kein DOAK ist bei CKD-Patienten mit terminaler Nierenerkrankung, ob mit oder ohne Dialysetherapie, zugelassen. DOAK sind nicht empfohlen bei nierentransplantierten Patienten, die unter Immunsuppression mit Calcineurin-Hemmern stehen. Bei diesen Patienten ist die konven-tionelle Therapie mit VKA die einzige Möglichkeit und muss aufgrund potenziell uner-wünschter Nebenwirkungen engmaschig kontrolliert werden.

Keywords

atrial fibrillation - dialysis - anticoagulation - calcineurin-inhibitors

Schlüsselwörter

Vorhofflimmern - Dialyse - Antikoagulation - Calcineurin-Hemmer

Full Text

References

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