心房颤动合并慢性肾脏病应用抗凝药物的认识
梁世龙 杨环

广西中医药大学研究生院，广西南宁，530000；

摘要：口服抗凝药物是治疗心房颤动（Atrial fibrillation，AF，房颤）主要方式。慢性肾脏病（Chronic kidney disease，CKD）的患者存在着“出血、血栓”的风险，服用抗凝药物可能会增加出血风险。若两者同时合并，服用抗凝药物可能就会增加出血风险。如何根据肾功能结果选择合适的抗凝药物剂量以达到理想的抗凝疗效？对于进展至终末期肾脏病（End-stage renal disease，ESRD）阶段的患者，左心耳封堵术是否可以代替抗凝药物？就上述问题，本综述总结了近期相关文献报道的内容，并作出相应的理解。

关键词：心房颤动；慢性肾脏病；透析；左心耳封堵术；抗凝药物

参考文献

[1]上海市肾内科临床质量控制中心专家组. 慢性肾脏病早期筛查､诊断及防治指南(2022年版)[J]. 中华肾脏病杂志, 2022, 38(5): 453-464.

[2]慢性肾脏病非瓣膜性心房颤动抗凝管理工作组,韦洮.慢性肾脏病合并非瓣膜性心房颤动患者抗凝管理的专家共识[J].中国血液净化,2023,22(08):561-573.

[3]龙国会,宋沧桑,李兴德,等.心房颤动合并慢性肾脏病患者口服抗凝药物治疗的研究进展[J].中国药物评价,2022,39(01):54-60.

[4]Du X, Guo L, Xia S, et al. Atrial fibrillation prevalence, awareness and management in a nationwide survey of adults in China. Heart. 2021 Jan 28;107(7):535–41. 

[5]Brodsky SV, Mhaskar NS,Thiruveedi S,et al. Acute kidney injury aggravated by treatment initiation with apixaban: Another twist of anticoagulant-related nephropathy[J]. Kidney Res Clin Pract. 2017 Dec;36(4):387-392. 

[6]李文,董星彤,贾强,等.服用利伐沙班是冠心病或非瓣膜性 房颤患者发生急性肾脏病的危险因素[J]. 中华肾脏病杂志,2020,36( 10) : 744-749.

[7]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[J]. Circulation. 2013 Jan 15;127(2):224-32. 

[8]Yao X, Inselman JW, Ross JS,et al.Comparative Effectiveness and Safety of Oral Anticoagulants Across Kidney Function in Patients With Atrial Fibrillation[J]. Circ Cardiovasc Qual Outcomes. 2020 Oct;13(10):e006515.

[9]Harrington J,Carnicelli AP,Hua K,et al. Direct Oral Anticoagulants Versus Warfarin Across the Spectrum of Kidney Function: Patient-Level Network Meta-Analyses From COMBINE AF[J]. Circulation. 2023 Jun 6;147(23):1748-1757.

[10]Yao RJR,Holmes DN,Andrade JG,et al. Variability in Nonvitamin K Oral Anticoagulant Dose Eligibility and Adjustment According to Renal Formulae and Clinical Outcomes in Patients With Atrial Fibrillation With and Without Chronic Kidney Disease: Insights From ORBIT-AF II[J]. Am Heart Assoc. 2023 Mar 21;12(6):e026605.

[11]中华医学会心血管病学分会, 中国生物医学工程学会心律分会. 心AF动诊断和治疗中国指南 [J] . 中华心血管病杂志, 2023, 51(6) : 572-618.

[12]Stanifer JW,Pokorney SD,Chertow GM,et al. Apixaban Versus Warfarin in Patients With Atrial Fibrillation and Advanced Chronic Kidney Disease[J]. Circulation. 2020 Apr 28;141(17):1384-1392. 

[13]Halperin LF, Lee MK,Liew J,et al. Anticoagulation for Patients With Atrial Fibrillation and End-Stage Renal Disease on Dialysis: A National Survey[J]. Can J Cardiol. 2021 Jun;37(6):924-928. 

[14]Miao B,Sood N,Bunz TJ,et al. Rivaroxaban versus apixaban in non-valvular atrial fibrillation patients with end-stage renal disease or receiving dialysis[J]. Eur J Haematol.  2020 Apr;104(4):328-335.

[15]Kyriakoulis I,Adamou A,Stamatiou I,et al. Efficacy and safety of direct oral anticoagulants vs vitamin K antagonists in patients with atrial fibrillation and end-stage renal disease on hemodialysis: A systematic review and meta-analysis[J]. Eur J Intern Med. 2024 Jan;119:45-52. 

[16]Genovesi S, Porcu L,Slaviero G,et al. Correction to: Outcomes on safety and efficacy of left atrial appendage occlusion in end stage renal disease patients undergoing dialysis[J]. Nephrol. 2021 Feb;34(1):63-73.

[17]陈敏,任邦嘉欣,李文韬,等.左心耳封堵术治疗心房颤动合并慢性肾脏病的研究进展[J].中国胸心血管外科临床杂志,2024,31(07):1066-1070.