Anticoagulation in chronic kidney disease: from guidelines to clinical practice

Aursulesei, Viviana; Costache, Irina Iuliana

doi:10.1002/clc.23196

Cited by 106 publications

(79 citation statements)

References 36 publications

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“…A 30% reduction in dose may be needed in those with severe CKD (Table 1 ). 5,16 Low-molecular-weight heparins Enoxaparin, dalteparin and tinzaparin have largely replaced UFHs in clinical practice due to ease of administration and predictable pharmacokinetics requiring once or twice daily dosing. 5 They are primarily inhibitors of factor Xa through antithrombin with variable effects on other coagulation factors.…”

Section: Unfractionated Heparinmentioning

confidence: 99%

Anticoagulant strategies for the patient with chronic kidney disease

et al. 2020

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Chronic kidney disease (CKD) is a global health problem affecting up to 14% of the adult population in developed countries. On the basis of current guidelines, patients with CKD will often fulfi l criteria for both short-term and long-term anticoagulation. Paradoxically, patients with CKD are not only at a higher risk of thrombosis, they are also at increased risk of bleeding. Furthermore, the pharmacokinetics and pharmacodynamics of many anticoagulant therapies are signifi cantly affected by renal dysfunction. In addition, patients with advanced CKD are often systematically excluded from major clinical trials. As such, the decision on whether to anticoagulate or not, and if so with what agent, poses signifi cant challenges. A solid understanding of the condition in question and the available treatments is required to make an informed judgement call. An in-depth appreciation of the advantages and disadvantages of the currently available anticoagulants is a key element in the decision-making process.

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Section: Unfractionated Heparinmentioning

confidence: 99%

Anticoagulant strategies for the patient with chronic kidney disease

et al. 2020

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“…28 There is a great degree of platelet dysfunction among ESRD owing to decreased platelet activity, recruitment, adhesion, and aggregation along with impaired interaction among platelets and endothelium. 29,30 In a study evaluating hemostasis among ESRD patients, authors found decreased thrombin generating capacity and clopidogrel like platelet dysfunction. 25,31 Furthermore, patients on HD are frequently given intravenous heparin during the treatment which can increase the risk of bleeding.…”

Section: Pathophysiology Of Increased Risk Of Bleeding In Esrdmentioning

confidence: 99%

“…On one hand ESRD patients are hypercoagulable, while on the other, they are at an increased risk of bleeding due to abnormal primary hemostasis involving vasoconstriction, platelet adhesion, and aggregation rather than impairment of secondary hemostasis mechanisms (coagulation pathways) or fibrinolysis [ 28 ]. There is a great degree of platelet dysfunction among ESRD owing to decreased platelet activity, recruitment, adhesion, and aggregation along with impaired interaction among platelets and endothelium [ 29 , 30 ]. In a study evaluating hemostasis among ESRD patients, authors found decreased thrombin generating capacity and clopidogrel like platelet dysfunction [ 25 , 31 ].…”

Section: Pathophysiology Of Increased Risk Of Bleeding In Esrdmentioning

confidence: 99%

Anticoagulation in Patients with End-Stage Renal Disease and Atrial Fibrillation: Confusion, Concerns and Consequences

Goel¹,

Jain²,

Haddad³

et al. 2020

J Stroke

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End-stage renal disease (ESRD) patients have a higher prevalence of diabetes mellitus, hypertension, congestive heart failure and advanced age, along with an increased incidence of non-valvular atrial fibrillation (AF), thereby increasing the risk for cerebrovascular accidents. Systemic anticoagulation is therefore recommended in patients with ESRD with AF to reduce the risk and complications from thromboembolism. Paradoxically, these patients are at an increased risk of bleeding due to great degree of platelet dysfunction and impaired interaction between platelet and endothelium. Currently, CHA<sub>2</sub>DS<sub>2</sub>-VASc and Hypertension, Abnormal liver/kidney function, Stroke, Bleeding, Labile INR, Elderly, Drugs or alcohol (HAS-BLED) are the recommended models for stroke risk stratification and bleeding risk assessment in patients with AF. There is conflicting data regarding benefits and risks of medications such as antiplatelet agents, warfarin and direct oral anticoagulants in ESRD patients with AF. Moreover, there is no randomized controlled trial data to guide the clinical decision making. Hence, a multi-disciplinary approach with annual re-evaluation of treatment goals and risk-benefit assessment has been recommended. In this article, we review the current recommendations with risks and benefits of anticoagulation in patients with ESRD with AF.

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“…Nevertheless, it is inappropriate to use OAC in people with AF and kidney disease [19] owing to a high risk of bleeding [20]. Some novel OAC, referred to as direct oral anticoagulants (DOACs), are mainly excreted by the kidney; thus, dose adjustment is needed in people with kidney disease [21,22]. Furthermore, kidney disease is risk factor for bleeding [23][24][25].…”

Section: Introductionmentioning

confidence: 99%

Increased Incident Ischemic Stroke Risk in Advanced Kidney Disease: A Large-Scale Real-World Data Study

et al. 2020

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Introduction: Evidence using real-world data is sparse regarding the effects of oral anticoagulants (OACs) among patients with kidney disease. The aim of this study was to investigate the effects of kidney disease on ischemic stroke (IS) or systemic embolism (SE) among patients taking OAC, using large-scale real-world data in Japan. Methods: This was a retrospective cohort study using claims data and health checkup data from health insurance associations in Japan, from January 2005 to June 2017. We enrolled 21,581 patients diagnosed with atrial fibrillation (AF). Of the total population, 11,848 (54.9%) patients were taking OAC. A Cox proportional hazards model was used to examine the effect of kidney disease on IS/ SE with or without OAC. Results: During follow-up, 208 participants who were not taking OAC (mean follow-up 2.6 years) and 200 who were taking OAC (mean follow-up 3.0 years) experienced IS/SE. The % IS/SE incidence rates with and without kidney disease were 2.42/person-year and 0.63/person-year in the total population, 3.66/person-year and 0.76/personyear in the group without OAC use, and 1.52/person-year and 0.55/person-year in patients with OAC use, respectively. Hazard ratios (HRs) and 95% confidence intervals (CIs) of kidney disease for IS/SE were high, irrespective of OAC, even after adjustment: adjusted HR 2.62 (95% CI: 1.72-3.99) without OAC and adjusted HR 2.03 (95% CI: 1.20-3.44) with OAC; p = 0.193 for interaction between no OAC and OAC. Although bleeding risk was also high for kidney disease irrespective of OAC use (HR 2.93 [95% CI: 2.27-3.77] in the total population, HR 3.08 [95% CI: 2.15-4.43] in the group without OAC, and HR 2.73 [95% CI: 1.90-3.91] in the group with OAC use), net clinical benefit indicated that the benefit of OAC use exceeded the risk of bleeding: HR 4.50 (95% CI: 0.76-8.23) among those with kidney disease and HR 0.35 (95% CI: 0.04-0.66) among those without kidney disease. Conclusion: Although we found that OAC use was effective and recommended for patients with AF, advanced kidney disease is still an independent risk factor for IS/SE, even in patients taking OAC. Physicians should be aware of this risk and strictly control modifiable risk factors, regardless of OAC use.

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Anticoagulation in chronic kidney disease: from guidelines to clinical practice

Cited by 106 publications

References 36 publications

Anticoagulant strategies for the patient with chronic kidney disease

Anticoagulant strategies for the patient with chronic kidney disease

Anticoagulation in Patients with End-Stage Renal Disease and Atrial Fibrillation: Confusion, Concerns and Consequences

Increased Incident Ischemic Stroke Risk in Advanced Kidney Disease: A Large-Scale Real-World Data Study

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