Renal decline in patients with non-valvular atrial fibrillation treated with rivaroxaban or warfarin: A population-based study from the United Kingdom

Abstract

Background: Reports suggest that renal decline is greater among patients with non-valvular atrial fibrillation (NVAF) treated chronically with warfarin vs. some non-vitamin K antagonist oral anticoagulants. Methods and results: Using primary care electronic health records from the United Kingdom we followed adults with NVAF and who started rivaroxaban (20 mg/day, N = 5338) or warfarin (N = 6314), excluding those with estimated glomerular filtration rate (eGFR) <50 ml/min/1.73m 2 , end-stage renal disease (ESRD) or no eGFR or serum creatinine (SCr) values recorded in the previous year. Outcomes were: doubling SCr levels, ≥30% decline in eGFR and progression to ESRD. We calculated adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) for each outcome. Average eGFR slope was estimated using mixed model regression. After a mean follow-up 2.5 years, the number of incident cases of adverse renal events within the two cohorts was: doubling SCr (n = 322), ≥30% decline in eGFR (n = 1179), and progression to ESRD (n = 22). Adjusted HRs (95% CIs) for the renal outcomes among rivaroxaban vs. warfarin users were: doubling SCr, 0.63 (0.49-0.81); ≥30% decline in eGFR, 0.76 (0.67-0.86); ESRD, 0.77 (0.29-2.04). Similar results were observed among patients with diabetes or heart failure. Estimated mean decline in renal function over the study period was 2.03 ml/min/1.73 m 2 /year among warfarin users and 1.65 ml/min/1.73 m 2 /year among rivaroxaban users (p = 0.03). Conclusions: We found clear evidence that patients with NVAF, preserved renal function at baseline and treated with rivaroxaban had a markedly reduced risk and rate of renal decline compared with those treated with warfarin.

Risk and Management of Bleeding Complications with Direct Oral Anticoagulants in Patients with Atrial Fibrillation and Venous Thromboembolism: a Narrative Review

“…Data from systematic reviews and meta-analyses have shown that, in patients with moderate CKD (eGFR 30–59 mL/min) and AF or VTE, DOACs compared to warfarin have a superior or equivalent safety and efficacy profile [ 93 , 94 ]. Post-hoc analyses of phase 3 RCTs and observational data revealed that DOACs, in particular dabigatran and rivaroxaban, were associated with reduced loss of renal function compared to warfarin [ 90 , 95 ].…”

Factors associated with disease progression in patients with atrial fibrillation and heart failure anticoagulated with rivaroxaban

“…14,15 Although renal function decline is common among patients with AF, different studies have shown that compared with warfarin, rivaroxaban has a lower risk of renal function impairment. [32][33][34] In our study there was a modest reduction of renal function that could be explained by the high risk clinical profile (i.e., elderly patients with HF, AF, and many comorbidities). Although low diastolic blood pressure was associated with HF worsening, the worse clinical profile of these patients could explain at least in part this point.…”

Cardiac and renal outcomes of direct oral anticoagulants in patients with atrial fibrillation

“…Other studies found that rivaroxaban was associated with lower risks of a ≥30% decline in the eGFR, doubling of serum creatinine levels, and AKI than warfarin. 2,4,[6][7][8][9] When we stratified patients treated with the standard and off-label rivaroxaban doses to those treated with warfarin to compare their effects on renal function, we found that those treated with the off-label rivaroxaban dose had significantly higher risks of the composite of cardiac and renal events and a ≥30% decline in the eGFR than those treated with warfarin. This effect was not observed in patients treated with the standard rivaroxaban dose.…”

“…Some studies have reported that dabigatran and rivaroxaban were associated with a lower risk of eGFR decline than warfarin. [4][5][6][7][8][9] A retrospective cohort study conducted in Taiwan showed that warfarin was associated with a significantly higher risk of AKI than DOACs. However, a comparison of dabigatran with other anti-factor Xa inhibitors indicated no difference.…”

“…Several studies have used real‐world data to compare the effects of dabigatran, rivaroxaban, apixaban and warfarin on renal outcomes, including changes in the estimated glomerular filtration rate (eGFR) and serum creatinine and the occurrence of acute kidney injury (AKI) and renal failure (RF) events, in different countries. Some studies have reported that dabigatran and rivaroxaban were associated with a lower risk of eGFR decline than warfarin 4–9 . A retrospective cohort study conducted in Taiwan showed that warfarin was associated with a significantly higher risk of AKI than DOACs.…”