Antiplatelet and Antithrombotic Therapy in Acute Coronary Syndrome in Patients with Chronic Kidney Disease

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.

Keywords: Acute coronary syndrome, antiplatelet therapy, antithrombotic therapy, chronic kidney disease, glomerular filtration rate.