Am J Cardiol：肾功能不全与房颤抗凝患者不良转归相关

　　西班牙学者的一项研究表明，在接受稳定抗凝治疗的房颤患者中，肾功能不全与血栓形成/血管事件、出血和死亡密切相关。论文于2013年1月21日在线发表于《美国心脏病学杂志》（Am J Cardiol）。

　　此项研究共纳入978例接受稳定抗凝治疗的序贯性患者。利用MDRD公式在入组和随访2年时计算估计肾小球滤过率（eGFR）。记录随访期间不良事件，其中包括血栓形成/血管事件、大出血和死亡）。在886例（90.6%）患者中分析肾功能纵向改变。

　　结果显示，基线时平均eGFR为70.24 ml/min/1.73m²。随访期间，eGFR较低与血栓形成/血管事件、出血和死亡具有相关性。将基线eGFR <30 ml/min/1.73m²的患者排除之后，随访期间eGFR降低>>10 ml/min/1.73m²的患者为181例（21%）。心衰、基线eGFR和CHADS₂评分与随访期间严重肾损伤具有相关性（p= 0.010、p <0.001和p = 0.003）。

Renal Impairment in a “Real-Life” Cohort of Anticoagulated Patients With Atrial Fibrillation (Implications for Thromboembolism and Bleeding)

Renal dysfunction is highly prevalent among patients with atrial fibrillation (AF) and confers an increased risk of thrombotic and bleeding complications. We evaluated the effect of renal function on prognosis in anticoagulated patients with AF and assessed the changes in renal function during a long-term follow-up period. We recruited 978 consecutive stable anticoagulated patients with AF from our outpatient anticoagulation clinic (international normalized ratio 2.0 to 3.0 within the previous 6 months). The estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease equation at inclusion and 2 years of follow-up. Adverse events were recorded during follow-up (thrombotic/vascular events, major bleeding episodes, and mortality). Longitudinal changes in renal function were analyzed in 886 patients (90.6%). At baseline, the median eGFR using the Modification of Diet in Renal Disease equation was 70.24 ml/min/1.73 m2 (interquartile range 46.79 to 72.52). During follow-up, a low eGFR was associated with thrombotic/vascular events, with every 30 ml/min/1.73 m2 eGFR decrease (hazard ratio 1.42, 95% confidence interval [CI] 1.11 to 1.83, p = 0.006), bleeding (hazard ratio 1.44, 95% CI 1.08 to 1.94, p = 0.015), and mortality (hazard ratio 1.47, 95% CI 1.13 to 1.91, p = 0.004). After excluding patients with a baseline eGFR <30 ml/min/1.73 m2, the mean eGFR in our cohort decreased >10 ml/min/1.73 m2 in 181 patients (21%) during the follow-up period. The variables associated with severe renal impairment during follow-up were heart failure (odds ratio 3.58, 95% CI 1.36 to 9.42, p = 0.010), basal eGFR (odds ratio 6.34, 95% CI 2.44 to 16.50, p <0.001), and CHADS2 (Congestive heart failure, Hypertension, Age >75 years, Diabetes mellitus, and previous Stroke or transient ischemic attack [doubled]) score (odds ratio 1.63, 95% CI 1.19 to 2.23, p = 0.003). In conclusion, the presence of impaired renal function was closely related to thrombotic/vascular events, bleeding, and mortality in anticoagulated patients with AF. During follow-up, 1/5 of the patients had significant impairment in renal function. Importantly, normal or mild renal dysfunction at baseline did not exclude the subsequent development of severe renal dysfunction during the follow-up period.