Статья
Нюансы антикоагулянтной терапии у пациентов с хронической болезнью почек и фибрилляцией предсердий
Скорость клубочковой фильтрации (СКФ) снижается с возрастом после 50 лет. Число пациентов с фибрилляцией предсердий (ФП) и хронической болезнью почек (ХБП) ежегодно увеличивается. Риск развития ишемического инсульта и тромбоэмболических осложнений, как и риск кровотечений, значительно выше у пациентов с ФП при наличии у них сопутствующей дисфункции почек. Результаты четырех рандомизированных клинических исследований (РКИ) продемонстрировали преимущества новых прямых пероральных антикоагулянтов (ППОАК) по сравнению с варфарином, однако эти РКИ имели серьезные ограничения, обусловленные включением относительно низкой доли пациентов с выраженной ХБП. Исследование ROCKET-AF отличалось от других РКИ (RE-LY, ARISTOTLE) более высокими рисками у пациентов с ФП, оцененными по шкалам CHADS2 и HAS-BLED. Международное нормализованное отношение, находящееся вне терапевтического окна, ассоциировано с ухудшением функции почек у лиц с ФП, принимающих варфарин. У пациентов с клинически значимой дисфункцией почек необходимо уменьшение дозы ППОАК, так как все ППОАК в определенной мере выводятся почками. Пренебрежение рекомендациями в уменьшении дозы ППОАК у пациентов со сниженной функцией почек может привести к повышению риска кровотечений, и, наоборот, некорректное снижение дозы без четких показаний может снизить эффективность ППОАК в профилактике инсульта. В данной статье обсуждаются фармакологические характеристики ППОАК в зависимости от степени нарушения функции почек, важные нюансы при выборе антикоагулянтной терапии ППОАК у пациентов с сосуществующими ФП и ХБП.
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