Antiplatelet and Antithrombotic Therapy in Acute Coronary Syndrome in Patients with Chronic Kidney Disease
Pp. 121-139 (19)
Mahmut Altındal and Mustafa Arıcı
Chronic kidney disease (CKD) and acute kidney injury (AKI) after acute
coronary syndrome (ACS) are strong predictors of morbidity and mortality in patients
with ACS. Patients with concomitant kidney and cardiovascular disease constitute a
population that is difficult to treat. There are limited data since patients with CKD are
usually excluded from cardiovascular studies. Benefits of antiplatelet and antihrombotic
therapy must be balanced with risk of adverse events. Kidney function should routinely
be evaluated in patients with ACS when such therapies administered. Medications
should be used with caution in patients with kidney dysfunction and estimated
glomerular filtration rate should be the essential measure used for dosage adjustments.
Although additional data are required for evaluation of aspirin's benefit-to-risk ratio in
this special population due to inconsistent findings in clinical trials, aspirin is the usual
practice and recommended without dose adjustment. Unfractionated heparin, generally
do not warrant specific dose adjustment in face of kidney dysfunction. Factor Xa
inhibitors, low-molecular-weight heparins and direct thrombin inhibitors except
argatroban are predominantly cleared by the kidneys. Reduced doses and frequent
monitoring of anticoagulation are indicated when these agents are used in patients with
kidney dysfunction. Dose adjustment is usually not required for clopidogrel, prasugrel
and ticagrelor in patients with renal impairment. In contrast to abciximab, both
eptifibatide and tirofiban are largely eliminated via renal excretion thus, careful dose
tailoring is warranted among patients with kidney disease.
Acute coronary syndrome, antiplatelet therapy, antithrombotic
therapy, chronic kidney disease, glomerular filtration rate.
Hacettepe University Faculty of Medicine Department of Nephrology 06100-Ankara, TURKEY.