Efficacy and safety of direct oral anticoagulants in patients with atrial fibrillation and chronic kidney disease

Abstract

Background Direct oral anticoagulants (DOACs) are effective alternatives to warfarin for stroke prevention in patients with atrial fibrillation (AF) including patients with CKD III. However, data on patient outcomes with DOACs for advanced CKD are limited, while warfarin use is controversial. Methods A retrospective study of patients with AF using DOACs and CKD stages III‐V was conducted. The primary outcomes were stroke or systemic embolism and major bleeding while on DOAC therapy among CKD IV and V patients. Rates of outcomes from the DOAC trials and from previous studies of warfarin in CKD were referenced. Results Of 316 patients reviewed, 152 were included with mean CrCl of 38.8 mL/min. Stroke and systemic embolism occurred at a rate of 1.17 per 100 person‐years, with no significant difference between CKD IV/V and CKD III (P = .567). Rates were comparable to DOAC use from the DOAC trials, and lower than rates in studies of warfarin in CKD IV/V patients. There was a nonstatistically significant trend toward increased major bleeding in CKD IV/V patients. Rates of major bleeding in CKD III to V subjects were comparable to published rates for warfarin users with similar levels of renal impairment. Conclusions In our study, DOACs appeared to be as efficacious and safe in CKD IV and V as in CKD III. In addition, DOACs appeared to be more effective than, and as safe as warfarin when compared with reference studies of patients with advanced CKD. Our findings support the use of DOACs for thromboembolism prevention in patients with advanced CKD and AF.

Direct oral anticoagulants in patients with atrial fibrillation and chronic kidney disease

“…However, in randomized trials showing the efficacy and safety of the DOACs, severe and end‐stage CKD patients were excluded. Despite this study support use of DOACs in patients with severe CKD and atrial fibrillation, there are some unanswered questions.…”

“…The recommended use of Apixaban was 5 mg twice daily with a reduction in dose to 2.5 mg twice daily for either ≥80 years of age or body weight ≤60 kg . In this study, the mean age of the patients was as high as 78.6 years may need to dose reduction. Likewise, there is no information about the average weight of patients, which is one of the important criteria for dose reduction.…”

“…2 First, it was reported that CKD patients with stage 4-5 renal failure who underwent hemodialysis and peritoneal dialysis included this study. 1 However, there is no information about how many of these patients had hemodialysis or peritoneal dialysis. Patients who needed hemodialysis or peritoneal dialysis should be indicated separately because of increased bleeding risk than patients who did not.…”

“…We read the article entitled “Efficacy and safety of direct oral anticoagulants in patients with atrial fibrillation and chronic kidney disease” by Bhatia et al with interest . The use of vitamin K antagonists (VKAs) in chronic kidney disease (CKD) patients has several difficulties.…”

“…First, it was reported that CKD patients with stage 4‐5 renal failure who underwent hemodialysis and peritoneal dialysis included this study . However, there is no information about how many of these patients had hemodialysis or peritoneal dialysis.…”