Antikoagulation bei Patienten mit chronischer Niereninsuffizienz – Therapie von Vorhofflimmern und Schlaganfall

Besonders bei älteren Patienten mit eingeschränkter Nierenfunktion besteht bei Vorhofflimmern ein erhöhtes Schlaganfallrisiko. Andererseits ist insbesondere unter Vitamin-K-Antagonisten mit einer erhöhten Blutungsrate zu rechnen, sodass eine sorgfältige Indikationsstellung und Überwachung dieser Risikopatienten erforderlich ist. Auch ist die Effektivität der Vitamin-K-Antagonisten bei präterminaler und terminaler Niereninsuffizienz, insbesondere aufgrund des hohen Blutungsrisikos eingeschränkt. Bei den großen Zulassungsstudien ist beim Einsatz der neuen oralen Antikoagulantien bis zu einer Nierenfunktionseinschränkung von ≥ 30 ml/min mit einem besseren Nutzen/Risiko-Verhältnis als bei den Vitamin-K-Antagonisten zu rechnen. Der Einsatz der neuen oralen Antikoagulantien (NOAK) erfordert die Kenntnis ihrer Pharmakokinetik, insbesondere der renalen Eliminationsrate. Auch ist eine sorgfältige Indikationsstellung gerade beim älteren Patienten > 80 Jahre wichtig, die oft unter zusätzlicher Thrombozytenaggregationshemmung stehen. Nicht zuletzt ist eine regelmäßige Kontrolle der Nierenfunktion entscheidend, da sich diese innerhalb von kurzer Zeit ändern kann.

Especially in elderly patients with limited renal function atrial fibrillation is associated with an increased risk of stroke. On the other hand, above under all vitamin K antagonists an increased bleeding rate must be expected so that careful diagnostic evaluation and monitoring are necessary for these high-risk patients. Furthermore, the efficacy of vitamin K antagonists in preterminal and terminal renal failure is limited, especially due to the higher risk of bleeding. In the large clinical studies the use of the new oral anticoagulants is expected to have a better risk/benefit balance up to a renal function insufficiency of ≥ 30 ml/min than the vitamin K antagonists. The administration of the new oral anticoagulants (NOAC) requires knowledge of their pharmacokinetics, especially the renal excretion rate. Also a careful diagnostic evaluation is important especially for patients older than 80 years, as these are often undergoing additional thrombocyte aggregation inhibition. Last but not least a regular monitoring of renal function is decisive as this can change within a short time.

Key words

Anticoagulation - new oral anticoagulants (NOAC) - vitamin K antagonists - chronic renal insufficiency - atrial fibrillation - stroke - bleeding rate

• Literatur

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