Gli Anticoagulanti Orali Non Vitamina K-dipendenti Nei Pazienti Con Fibrillazione Atriale Non Valvolare ed End-stage Renal Disease (ESRD). Un Matrimonio Impossibile?

Di Lullo Luca; Fulvio Floccari; Rodolfo Rivera; Vincenzo Barbera; Antonio Bellasi; Mario Cozzolino; Antonio Selvi; Francesca Santoboni; Antonio De Pascalis; Claudio Ronco

doi:10.33393/gcnd.2017.653

Authors

Di Lullo Luca UOC Nefrologia e Dialisi, Ospedale “L. Parodi-Delfino”, Colleferro (RM)
Fulvio Floccari UOC Nefrologia e Dialisi, Ospedale “S. Paolo”, Civitavecchia (RM)
Rodolfo Rivera Divisione di Nefrologia, Ospedale “S. Gerardo”, Monza
Vincenzo Barbera UOC Nefrologia e Dialisi, Ospedale “L. Parodi-Delfino”, Colleferro (RM)
Antonio Bellasi UOC Nefrologia e Dialisi, ASTT Lariana, Ospedale “S. Anna”, Como
Mario Cozzolino Dipartimento di Scienze della Salute, Divisione di Nefrologia, Ospedale “S. Paolo”, Milano
Antonio Selvi Nefrologia e Dialisi, USL Umbria 1, Todi (PG)
Francesca Santoboni UOC Nefrologia e Dialisi, Ospedale “L. Parodi-Delfino”, Colleferro (RM)
Antonio De Pascalis UOC Nefrologia e Dialisi, Ospedale “V. Fazzi”, Lecce
Claudio Ronco International Renal Research Institute, Ospedale “S. Bortolo”, Vicenza

DOI:

https://doi.org/10.33393/gcnd.2017.653

Keywords:

Anticoagulation therapy, Atrial fibrillation, Chronic kidney disease, Non-vitamin-K oral anticoagulants (NOACs), Warfarin

Abstract

Atrial fibrillation (AF) is the most common arrhythmia in patients with chronic kidney disease (CKD). In this population, AF is associated with an increased risk of thromboembolism and stroke as a result of a progressive decline in the glomerular filtration rate. However, CKD patients, in particular those on renal replacement therapy, also have an increased risk of bleeding, especially from the gastrointestinal tract. Oral anticoagulation is the most effective form of thromboprophylaxis in patients with AF presenting an increased risk of stroke. Limited evidence of its efficacy, the increased risk of bleeding as well as some concern regarding the use of warfarin in CKD have often resulted in the underuse of anticoagulation in CKD patients. A large body of evidence suggests that non-vitamin-K-dependent oral anticoagulants (NOACs) significantly reduce the risk of stroke, intracranial hemorrhage and mortality. Hence, they are currently recommended for patients with AF at risk of stroke. However, the metabolism of NOACs is largely dependent on the kidneys for elimination and little is known about their use in patients with creatinine clearance <25 mL/min, who have been excluded from all pivotal phase III NOAC trials. This review focuses on the current pharmacokinetic, observational and prospective data on NOACs in patients affected by moderate to advanced CKD (creatinine clearance 15–49 mL/min) and in those on dialysis (Cardionephrology)