Antikoagulantna terapija u bolesnika s fibrilacijom atrija i kroničnom renalnom insuficijencijom

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Atrial fibrillation is the most common cardiac arrhythmia and it is associated with a significantly increased risk of stroke and systemic embolism. To reduce this risk it is important to start these patients on life-term oral anticoagulation. Many patients with atrial fibrillation also have some degree of renal insufficiency, which further increases the risk of stroke and thromboembolism, as well as the risk of bleeding. Therefore it is crucial to carefully choose a type of anticoagulant medication that is effective and safe for patients suffering from atrial fibrillation and renal insufficiency. There are two types of oral anticoagulants, vitamin K antagonists and new oral anticoagulants (NOAC). Warfarin is the most commonly used vitamin K antagonist, while NOACs include dabigatran, rivaroxaban, apixaban and edoxaban. Considering NOACs are mostly renally excreted, only patients with mild to moderate renal insufficiency were included in the original clinical trials, but these trials showed that NOACs are as effective or superior to warfarin and are now the treatment of choice for patients with atrial fibrillation and mild or moderate renal insufficiency. Few NOAC pharmacokinetic studies were performed and found doses of these drugs that produce stable plasma levels in patients with severe renal insufficiency and could be effective in preventing thromboembolism. The results of studies that included warfarin treatment in these patients are heterogeneous, showing it could produce a satisfactory anticoagulant effect or it could even increase the stroke risk. Major bleeding also seems to be less frequent in patients with severe renal insufficiency treated with NOACs then in those treated with warfarin. Besides bleeding, an important factor of safety to keep in mind while treating patients with renal insufficiency is the progression of their kidney disease and the development of acute kidney injury. A specific type of kidney injury known as anticoagulant related nephropathy is a severe adverse effect of oral anticoagulant therapy, related mostly to warfarin use. It can occur even in patients with mild renal insufficiency or normal kidney function, often leading to life-long hemodialysis. Considering their superior safety profile as well as the possibility of achieving stable plasma levels even in severe kidney disease, NOACs seem to be a better option for anticoagulant treatment of patients with atrial fibrillation and renal insufficiency.