Benefits and Harms of Oral Anticoagulant Therapy in Chronic Kidney Disease

Ha, Jeffrey; Neuen, Brendon L.; Cheng, Lap P.; Jun, Min; Toyama, Tadashi; Gallagher, Martin; Jardine, Meg; Sood, Manish M.; Garg, Amit X.; Palmer, Suetonia C.; Mark, Patrick B.; Wheeler, David C.; Jha, Vivekanand; Freedman, Ben; Johnson, David W.; Perkovic, Vlado; Badve, Sunil V.

doi:10.7326/m19-0087

Cited by 122 publications

(73 citation statements)

References 30 publications

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“…A recent larger systematic review and meta-analysis of 11 trials (16,787 participants) confirmed superiority of high-dose NOACs compared with vitamin K antagonists for stroke or systemic embolism (RR, 0.79; 95% CI, 0.66-0.93), hemorrhagic stroke (RR, 0.48; 95% CI, 0.30-0.76), and all-cause death (RR, 0.88; 95% CI, 0.78-0.99). 43 However, the reduction in major bleeding (RR, 0.80; 95% CI, 0.61-1.04) was nonsignificant when compared to warfarin. This meta-analysis was again limited only to patients with a creatinine clearance of >25 ml/ min, as no data were available for patients with more advanced CKD including dialysis-dependent CKD.…”

Section: Anticoagulantsmentioning

confidence: 95%

Prevention and treatment of stroke in patients with chronic kidney disease: an overview of evidence and current guidelines

Kelly

Rothwell

2020

Kidney International

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Chronic kidney disease is strongly associated with an increased risk of stroke, small vessel disease, and vascular dementia. Common vascular factors for stroke, such as hypertension, diabetes, and atrial fibrillation, are more prevalent in patients with chronic kidney disease, accounting for this association. However, factors unique to these patients, such as uremia, oxidative stress, and mineral and bone abnormalities, as well as dialysis-related factors are also believed to contribute to risk. Despite improvements in stroke treatment and survival in the general population, the rate of improvement in patients with chronic kidney disease, especially those who are dialysis dependent, has lagged behind. There is a lack of or conflicting evidence that those with renal disease, particularly when advanced or older, consistently derive benefit from currently available preventive and therapeutic interventions for stroke in the general population. In this review, we explore the complexities and challenges of these interventions in the population with renal disease.

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Section: Anticoagulantsmentioning

confidence: 95%

Prevention and treatment of stroke in patients with chronic kidney disease: an overview of evidence and current guidelines

Kelly

Rothwell

2020

Kidney International

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“…102 Anticoagulation has been used to maintain hemodialysis access patency, but its utility for this purpose is unclear and generally not recommended. 103 Data on DOACs in CKD are limited and largely derived from observational studies, which may be confounded. The major randomized studies leading to DOAC approvals for nonvalvular AF in the general population excluded patients with eGFR <25 ml/min per 1.73 m 2 .…”

Section: Ckd and Eskdmentioning

confidence: 99%

“…A recent metaanalysis evaluated 45 trials of patients with CKD or patients on hemodialysis (8 trials) for various indications. 103 All the hemodialysis trials studied only VKAs; the remaining studies excluded patients with severe CKD. In these analyses, DOACs had a lower risk of stroke (RR, 0.79; 95% CI, 0.66-0.93) and hemorrhagic stroke (RR, 0.48; 95% CI, 0.30-0.76) than did warfarin.…”

Section: Ckd and Eskdmentioning

confidence: 99%

Role of direct oral anticoagulants in patients with kidney disease

Derebail

Rheault

Kerlin

2020

Kidney International

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The anticoagulation field is experiencing a renaissance that began with regulatory approval of the direct thrombin inhibitor dabigatran, a direct oral anticoagulant (DOAC), in 2010. The DOAC medication class has rapidly evolved to include the additional approval of 4 direct factor Xa inhibitors. Commensurately, DOAC use has increased and collectively account for the majority of new anticoagulant prescriptions. Despite exclusion of patients with moderateto-severe kidney disease from most pivotal DOAC trials, DOACs are increasingly used in this setting. An advantage of DOACs is similar or improved antithrombotic efficacy with less bleeding risk when compared with traditional agents. Several post hoc analyses, retrospective studies, claims data studies, and meta-analyses suggest that these benefits extend to patients with kidney disease. However, the lack of randomized controlled trial data in specific kidney disease settings, with their unique pathophysiology, should be a call to action for the kidney community to systematically study these agents, especially because early data suggest that DOACs may pose less risk of anticoagulant-related nephropathy than do vitamin K antagonists. Most DOACs are renally cleared and are significantly protein bound in circulation; thus, the pharmacokinetics of these drugs are influenced by reduced renal function and proteinuria. DOACs are susceptible to altered metabolism by P-glycoprotein inhibitors and inducers, including drugs commonly used for the management of kidney disease comorbidities. We summarize the currently available literature on DOAC use in kidney disease and illustrate knowledge gaps that represent important opportunities for prospective investigation.

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“…All new oral anticoagulants are excreted through the kidney to a certain percentage (edoxaban 35%, rivaroxaban 35%, apixaban 25%). Therefore, it should be remembered that dose adjustment may be required in people with kidney failure (14). Since there was no renal failure in our case, no dose adjustment was required.…”

Section: Discussionmentioning

confidence: 83%

Edoxaban Kullanımına Bağlı Spontan Renal Hematom: Olgu Sunumu

İplikçi¹,

Efiloğlu²,

Yıldırım³

2020

Yeni Üroloji Dergisi

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Edoxaban faktör Xa'yı doğrudan baskılayan bir oral antikoagülan ilaçtır. Daha az ilaç etkileşimi ve rutin izleme ihtiyacını ortadan kaldırması nedeniyle; inme profilaksisi, venöz tromboemboli profilaksisi/tedavisi, akut koroner sendromların sekonder profilaksisi için hastalara daha iyi tedavi alternatifleri sağlamıştır. Kullanımı arttıkça klinisyenlerin potansiyel tedavi riskleri ve komplikasyon yönetiminden daha fazla haberdar olmaları gerekmektedir. Bu makalede, atriyal fibrilasyon nedenli inme profilaksisi için edoxaban kullanan hastada gelişen spontan renal hematom bildirilmektedir. Hemodinamik destek sağlanan, görüntülemeler ile izlenen ve multidisipliner açıdan tedavi ve takip kararları alınan hasta tüm çabalara rağmen hayatını kaybetti. Kanama pıhtılaşma değerlerini değiştirmedikleri için acil servise başvuran kanamalı hastalarda bu ilaçların kullanım anamnezi dikkatli alınmalıdır. Vakamızda da gösterildiği gibi kullanımları sırasında gelişebilecek ölümcül komplikasyonlar için tedavi algoritmaları geliştirebilmek için daha geniş vaka serilerine ve olgu sunumlarına ihtiyaç vardır.

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Benefits and Harms of Oral Anticoagulant Therapy in Chronic Kidney Disease

Cited by 122 publications

References 30 publications

Prevention and treatment of stroke in patients with chronic kidney disease: an overview of evidence and current guidelines

Prevention and treatment of stroke in patients with chronic kidney disease: an overview of evidence and current guidelines

Role of direct oral anticoagulants in patients with kidney disease

Edoxaban Kullanımına Bağlı Spontan Renal Hematom: Olgu Sunumu

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