Download PDF
Nervenheilkunde 2022; 41(06): 411-415
DOI: 10.1055/a-1819-4091
Schwerpunkt

Orale Antikoagulation bei Vorhofflimmern und stark eingeschränkter Nierenfunktion

Immer noch ungelöstOral anticoagulation in atrial fibrillation and end-stage renal diseaseAn unsolved problem
Shinwan Kany
1   Klinik für Kardiologie, Universitäres Herz- und Gefäßzentrum Hamburg, Universitätsklinikum Hamburg-Eppendorf
,
Günter Breithardt
2   Klinik für Kardiologie, Universitätsklinikum Münster
› Author Affiliations
› Further Information
Also available at
    Permissions and Reprints

ZUSAMMENFASSUNG

Vorhofflimmern ist die häufigste Herzrhythmusstörung. Weltweit ist die Prävalenz steigend und mit Komorbiditäten wie Niereninsuffizienz verbunden. Zur Prävention von Schlaganfällen sind Vitamin-K-Antagonisten (VKA) und Nicht-VKA orale Antikoagulanzien (NOAK) in nierenadaptierter Dosis nur bis zu einer Nierenfunktion mit einer glomerulären Filtrationsrate bis 15 mL/min verfügbar. Unterhalb dieser Nierenfunktion sowie für Patienten mit chronischer Hämodialyse gibt es keine hinreichende Evidenz für oder wider einer OAK. Große Observationsstudien aus den USA und skandinavischen Ländern zeigen Hinweise für ein erhöhtes Blutungsrisiko ohne signifikante Verbesserung von Mortalität oder Schlaganfällen. Die randomisierte kontrollierte VALKYRIE-Studie zeigte eine deutliche Überlegenheit von 10 mg Rivaroxaban (NOAK) im Vergleich zu VKA zur Prävention kardiovaskulärer Ereignisse bei Patienten mit VHF und chronischer Dialyse. Die randomisiert-kontrollierte AXADIA-AFNET-7-Studie vergleicht 2,5 mg Apixaban (NOAK) 2-mal täglich mit VKA in VHF-Patienten mit Dialyse und wird Mitte 2022 abgeschlossen sein. Dadurch werden wichtige neue Erkenntnisse in diesem sensiblen Bereich gewonnen.

ABSTRACT

Atrial fibrillation (AF) is the most common arrhythmia in the world. Prevalence is rising and co-morbidities like chronic kidney disease (CKD) are common. Oral anticoagulation (OAC) is used for stroke prevention in AF but limited to patients without reduced kidney function. Vitamin-K antagonists (VKA) and non-VKA oral anticoagulants (NOAC) are only available for patients with a glomerular filtration function (GFR) above 15 mL/min. In patients with lower GFR or on chronic hemodialysis limited data on efficacy in prevention of stroke is available. Observational data from large cohorts in the United States and Scandinavian countries hinted at increased risk for major bleedings without significant effects of mortality or strokes. The randomized-controlled VALKYRIE study showed that 10 mg of rivaroxaban (NOAC) was associated with less cardiovascular events compared with VKA. The randomized-controlled AXADIA-AFNET 7 study will compare apixaban 2.5 mg BID (NOAC) with VKA in patients with AF and chronic hemodialysis. Enrollment will end in June 2022 and the results will provide importance evidence in this field that has been noted for need for stronger evidence to adequately help AF patients with reduced kidney function.

Schlüsselwörter

Vorhofflimmern - orale Antikoagulation - Schlaganfall - Niereninsuffizienz - Dialyse

Key words

Atrial fibrillation - oral anticoagulation - stroke - hemodialysis - chronic kidney disease


Publication History

Article published online:
07 June 2022

© 2022. Thieme. All rights reserved.

© Georg Thieme Verlag KG Stuttgart · New York
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • Literatur

  • 1 Levey AS, Eckardt K-U, Dorman NM. et al Nomenclature for kidney function and disease: report of a Kidney Disease: Improving Global Outcomes (KDIGO) Consensus Conference. Kidney International 2020; 97: 1117-1129
    CrossrefPubMedSearch in Google Scholar
  • 2 Anonym Trends in Prevalence of Chronic Kidney Disease in the United States. Annals of Internal Medicine 2016; 165: 473-481
    CrossrefSearch in Google Scholar
  • 3 Jacob L, Breuer J, Kostev K. Prevalence of chronic diseases among older patients in German general practices. Ger Med Sci 2016; 14: Doc03-Doc03
    CrossrefPubMedSearch in Google Scholar
  • 4 Levin A, Stevens PE, Bilous RW. et al Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney international supplements 2013; 03: 1-150
    Search in Google Scholar
  • 5 Alonso A, Lopez FL, Matsushita K. et al Chronic Kidney Disease Is Associated With the Incidence of Atrial Fibrillation. Circulation 2011; 123: 2946-2953
    CrossrefPubMedSearch in Google Scholar
  • 6 Bansal N, Fan D, Hsu C. et al Incident Atrial Fibrillation and Risk of End-Stage Renal Disease in Adults With Chronic Kidney Disease. Circulation 2013; 127: 569-574
    CrossrefPubMedSearch in Google Scholar
  • 7 Zimmerman D, Sood MM, Rigatto C. et al Systematic review and meta-analysis of incidence, prevalence and outcomes of atrial fibrillation in patients on dialysis. Nephrology Dialysis Transplantation 2012; 27: 3816-3822
    CrossrefPubMedSearch in Google Scholar
  • 8 Watanabe H, Watanabe T, Sasaki S. et al Close bidirectional relationship between chronic kidney disease and atrial fibrillation: The Niigata preventive medicine study. American Heart Journal 2009; 158: 629-636
    CrossrefPubMedSearch in Google Scholar
  • 9 Ding WY, Gupta D, Wong CF. et al Pathophysiology of atrial fibrillation and chronic kidney disease. Cardiovascular Research 2020; 117: 1046-1059
    CrossrefPubMedSearch in Google Scholar
  • 10 Abramson JL, Jurkovitz CT, Vaccarino V. et al Chronic kidney disease, anemia, and incident stroke in a middle-aged, community-based population: The ARIC Study. Kidney International 2003; 64: 610-615
    CrossrefPubMedSearch in Google Scholar
  • 11 Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 1991; 22: 983-988
    CrossrefPubMedSearch in Google Scholar
  • 12 Lip GYH, Nieuwlaat R, Pisters R. et al Refining Clinical Risk Stratification for Predicting Stroke and Thromboembolism in Atrial Fibrillation Using a Novel Risk Factor-Based Approach: The Euro Heart Survey on Atrial Fibrillation. Chest 2010; 137: 263-272
    CrossrefPubMedSearch in Google Scholar
  • 13 Banerjee A, Fauchier L, Vourc’h P. et al Renal Impairment and Ischemic Stroke Risk Assessment in Patients With Atrial Fibrillation: The Loire Valley Atrial Fibrillation Project. Journal of the American College of Cardiology 2013; 61: 2079-2087
    CrossrefPubMedSearch in Google Scholar
  • 14 López-López JA, Sterne JAC, Thom HHZ. et al Oral anticoagulants for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis, and cost effectiveness analysis. BMJ 2017; 359: j5058
    CrossrefPubMedSearch in Google Scholar
  • 15 Granger CB, Alexander JH, McMurray JJV. et al Apixaban versus Warfarin in Patients with Atrial Fibrillation. New England Journal of Medicine 2011; 365: 981-992
    CrossrefPubMedSearch in Google Scholar
  • 16 Patel MR, Mahaffey KW, Garg J. et al Rivaroxaban versus Warfarin in Nonvalvular Atrial Fibrillation. New England Journal of Medicine 2011; 365: 883-891
    CrossrefPubMedSearch in Google Scholar
  • 17 Connolly SJ, Ezekowitz MD, Yusuf S. et al Dabigatran versus Warfarin in Patients with Atrial Fibrillation. New England Journal of Medicine 2009; 361: 1139-1151
    CrossrefPubMedSearch in Google Scholar
  • 18 Giugliano RP, Ruff CT, Braunwald E. et al Edoxaban versus Warfarin in Patients with Atrial Fibrillation. New England Journal of Medicine 2013; 369: 2093-2104
    CrossrefPubMedSearch in Google Scholar
  • 19 Reinecke H, Brand E, Mesters R. et al Dilemmas in the Management of Atrial Fibrillation in Chronic Kidney Disease. Journal of the American Society of Nephrology 2009; 20: 705
    CrossrefPubMedSearch in Google Scholar
  • 20 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 of Cardio-Thoracic Surgery (EACTS). Eur Heart J 2020
    CrossrefPubMedSearch in Google Scholar
  • 21 January CT, Wann LS, Calkins H. 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 in Collaboration With the Society of Thoracic Surgeons. Circulation 2019; 140: e125-e151
    CrossrefPubMedSearch in Google Scholar
  • 22 Dias C, Moore KT, Murphy J. et al Pharmacokinetics, Pharmacodynamics, and Safety of Single-Dose Rivaroxaban in Chronic Hemodialysis. American Journal of Nephrology 2016; 43: 229-236
    CrossrefPubMedSearch in Google Scholar
  • 23 Wang X, Tirucherai G, Marbury TC. et al Pharmacokinetics, pharmacodynamics, and safety of apixaban in subjects with end-stage renal disease on hemodialysis. J Clin Pharmacol 2016; 56: 628-636
    CrossrefPubMedSearch in Google Scholar
  • 24 Mavrakanas TA, Samer CF, Nessim SJ. et al Apixaban Pharmacokinetics at Steady State in Hemodialysis Patients. Journal of the American Society of Nephrology 2017; 28: 2241
    CrossrefPubMedSearch in Google Scholar
  • 25 Olesen JB, Lip GYH, Kamper A-L. et al Stroke and Bleeding in Atrial Fibrillation with Chronic Kidney Disease. New England Journal of Medicine 2012; 367: 625-635
    CrossrefPubMedSearch in Google Scholar
  • 26 Bonde AN, Lip GYH, Kamper A-L. et al Net Clinical Benefit of Antithrombotic Therapy in Patients With Atrial Fibrillation and Chronic Kidney Disease. Journal of the American College of Cardiology 2014; 64: 2471-2482
    CrossrefPubMedSearch in Google Scholar
  • 27 Shah M, Avgil Tsadok M. et al Warfarin Use and the Risk for Stroke and Bleeding in Patients With Atrial Fibrillation Undergoing Dialysis. Circulation 2014; 129: 1196-1203
    CrossrefPubMedSearch in Google Scholar
  • 28 Kuno T, Takagi H, Ando T. et al Oral Anticoagulation for Patients With Atrial Fibrillation on Long-Term Dialysis. Journal of the American College of Cardiology 2020; 75: 273-285
    CrossrefPubMedSearch in Google Scholar
  • 29 Schurgers LJ. Vitamin K: key vitamin in controlling vascular calcification in chronic kidney disease. Kidney International 2013; 83: 782-784
    CrossrefPubMedSearch in Google Scholar
  • 30 Olesen JB, Lip GY, Kamper AL. et al Stroke and bleeding in atrial fibrillation with chronic kidney disease. N Engl J Med 2012; 367: 625-635
    CrossrefPubMedSearch in Google Scholar
  • 31 Kumar S, de Lusignan S, McGovern A. et al Ischaemic stroke, haemorrhage, and mortality in older patients with chronic kidney disease newly started on anticoagulation for atrial fibrillation: a population based study from UK primary care. BMJ 2018; 360: k342
    CrossrefPubMedSearch in Google Scholar
  • 32 Chan KE, Edelman ER, Wenger JB. et al Dabigatran and Rivaroxaban Use in Atrial Fibrillation Patients on Hemodialysis. Circulation 2015; 131: 972-979
    CrossrefPubMedSearch in Google Scholar
  • 33 Siontis KC, Zhang X, Eckard A. et al Outcomes Associated With Apixaban Use in Patients With End-Stage Kidney Disease and Atrial Fibrillation in the United States. Circulation 2018; 138: 1519-1529
    CrossrefPubMedSearch in Google Scholar
  • 34 Pokorney Sean D, Black-Maier E, Hellkamp AS. et al Oral Anticoagulation and Cardiovascular Outcomes in Patients With Atrial Fibrillation and End-Stage Renal Disease. Journal of the American College of Cardiology 2020; 75: 1299-1308
    CrossrefPubMedSearch in Google Scholar
  • 35 Garlo KG, Steele DJR, Nigwekar SU. et al Demystifying the Benefits and Harms of Anticoagulation for Atrial Fibrillation in Chronic Kidney Disease. Clinical Journal of the American Society of Nephrology 2019; 14: 125
    CrossrefPubMedSearch in Google Scholar
  • 36 De Vriese AS, Caluwé R, Van Der Meersch H. et al Safety and Efficacy of Vitamin K Antagonists versus Rivaroxaban in Hemodialysis Patients with Atrial Fibrillation: A Multicenter Randomized Controlled Trial. Journal of the American Society of Nephrology 2021; 32: 1474
    CrossrefPubMedSearch in Google Scholar
  • 37 Sean Pokorney DK. Deepak Bhatt. RENal hemodialysis patients ALlocated apixaban versus warfarin in Atrial Fibrillation – RENAL-AF (11/17/2019). Stand: 02/14/2022
  • 38 Reinecke H, Jürgensmeyer S, Engelbertz C. et al Design and rationale of a randomised controlled trial comparing apixaban to phenprocoumon in patients with atrial fibrillation on chronic haemodialysis: the AXADIA-AFNET 8 study. BMJ Open 2018; 08: e022690-e022690
    CrossrefPubMedSearch in Google Scholar