Stroke, Major Bleeding, and Mortality Outcomes in Warfarin Users With Atrial Fibrillation and Chronic Kidney Disease

Dahal, Khagendra; Kunwar, Sumit; Rijal, Jharendra; Schulman, Peter; Lee, Juyong

doi:10.1378/chest.15-1719

Cited by 212 publications

(171 citation statements)

References 29 publications

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“…eGFR less than 30 ml/min), major guidelines discourage their use in these patients [32]. Although a recent meta-analysis finds that VKAs do not reduce stroke rate in ESRD patients on replacement therapy, and is associated with a 30% increase in major bleeding [13], some recent studies suggest that these patients with AF when treated with VKAs have a better survival compared with patients not anticoagulated. Warfarin benefit seems to be particularly evident in patients taking VKAs without interruption, and with an INR kept in therapeutic range [33,34].…”

Section: Using Direct Oral Anticoagulants In Patients With Chronic Kimentioning

confidence: 99%

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Dabigatran etexilate: appropriate use in patients with chronic kidney disease and in the elderly patients

Molteni

Minno

et al. 2017

Intern Emerg Med

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Dabigatran etexilate (DE) is a direct thrombin inhibitor, which has been approved for the treatment of non-valvular atrial fibrillation (AF), and for the prevention and treatment of venous thromboembolism (VTE). Despite large randomized clinical trials and independent observational studies providing robust data concerning DE safety and efficacy, some physicians still perceive mild-to-moderate renal impairment and old age as a relative contraindication to its use. In this article, we review the available scientific evidence supporting the use of DE in these clinical situations. Patients with AF and chronic kidney disease (CKD) are per se at high risk of stroke, bleeding and mortality. Although there is evidence of clinical benefit of anticoagulation in these patients, anticoagulant therapy requires caution and demands careful clinical monitoring, regardless of the drug used. In patients with no contraindication to its use, the clinical benefit of DE versus warfarin is independent of renal function. The elderly with AF are frequently undertreated because of the perception of high bleeding risk and limited clinical benefit. However, the clinical benefit of anticoagulation is independent of patient age, and age per se should not represent a contraindication to anticoagulation. DE has been extensively studied in the elderly, both in randomized clinical trials and in observational studies: DE 150 mg BID should not be used in patients 80 years of age or older, while DE 110 mg BID is as safe as warfarin. Intracranial haemorrhages reduction by DE compared with warfarin is preserved in the elderly. Therefore, mild and moderate CKD and being elderly should not deter physicians from prescribing DE. Furthermore, the availability of a specific antidote is expected to improve the safety of the use of DE in clinical practice.

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Section: Using Direct Oral Anticoagulants In Patients With Chronic Kimentioning

confidence: 99%

“…Although there is evidence of clinical benefit of anticoagulation in these patients, anticoagulant therapy requires caution and demands a careful clinical monitoring, regardless of the drug used [12,13]. In patients with no contraindication to its use, the clinical benefit of DE versus warfarin is independent of renal function [14].…”

Section: Introductionmentioning

confidence: 99%

Dabigatran etexilate: appropriate use in patients with chronic kidney disease and in the elderly patients

Molteni

Minno

et al. 2017

Intern Emerg Med

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“…Wykazano, że stosowanie warfaryny w nieschyłkowym stadium CKD wiąże się z redukcją ryzyka udarów niedokrwiennych mózgu/zatorowości obwodowej (HR 0,70, 95% CI 0,54-0,89; p = 0,004) i śmiertelności (HR 0,65, 95% CI 0,59-0,72; p < 0,00001). U pacjentów z ESRD warfaryna nie wpływała na redukcję ryzyka udarów mózgu (HR 1,12, 95% CI, 0,69-1,82; p = 0,65) ani śmier-telności (HR 0,96, 95% CI 0,81-1,13; p = 0,60), powodowała natomiast zwiększenie ryzyka wystąpienia poważnych krwawień [41]. U chorych hemodializowanych działanie VKA częściowo zastępuje antykoagulacja w postaci heparyny stosowanej 3 razy w tygodniu podczas hemodializy.…”

Section: Nowe Doustne Antykoagulanty U Chorych Z Af I Ckdunclassified

“…Okazało się, że ryzyko krwawienia u chorych z łagodnym upośledzeniem funkcji nerek leczonych apiksabanem było istotnie niższe (HR: 0,80, 95% CI 0,66-0,96) niż u chorych, u których stosowano VKA. U chorych z umiarkowanie i znacznie upośledzoną funkcją nerek ryzyko krwawienia było podobne w obu grupach (HR 1,01, 95% CI 0,49-2,10) [41].…”

Section: Nowe Doustne Antykoagulanty U Chorych Z Af I Ckdunclassified

Profilaktyka powikłań zakrzepowo-zatorowych u chorych z migotaniem przedsionków i przewlekłą chorobą nerek — pozycja nowych doustnych antykoagulantów

et al. 2017

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StreszczenieMigotanie przedsionków (AF) jest najczęściej występującym zaburzeniem rytmu serca w populacji ogólnej. Przewlekłą chorobę nerek (CKD) zalicza się do czynników ryzyka występowania AF, a jej obecność w znacznym stopniu wpływa na dobór leków stosowanych w profilaktyce powikłań zakrzepowo-zatorowych u pacjentów z tą arytmią. Ocena funkcji nerek jest niezbędna zarówno przed wdrożeniem leczenia przeciwkrzepliwego, jak i w jego trakcie. U chorych na CKD w 3. stadium za leki pierwszego wyboru uznaje się: apiksaban w dawce 5 mg 2 razy/dobę, riwaroksaban w dawce 15 mg raz/ /dobę oraz edoksaban w dawce 30 mg raz/dobę. Leki z grupy antagonistów witaminy K są przeznaczone dla chorych z AF i CKD niezależnie od jej stadium, są również dedykowane dla chorych dializowanych. U chorych z CKD należy wnikliwie rozważyć bilans korzyści do ryzyka terapii przeciwkrzepliwej, dotyczy to szczególnie chorych dializowanych ze względu na stosowanie heparyny w trakcie hemodializy. Nowe doniesienia na temat stosowania nowych doustnych antykoagulantów mogą w przyszłości rozszerzyć wskazania do stosowania tej grupy leków u chorych z CKD.

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“…In patients with AF and preserved renal function, anticoagulation therapy markedly reduces the risk of thromboembolism, but is associated with an increased risk of bleeding. In patients with CKD (not end-stage renal disease [ESRD]), the risk of bleeding due to vitamin K antagonists (VKA) is even greater, but the reduced risk of thromboembolic events is preserved [10]. Patients with ESRD undergoing hemodialysis represent a particular subgroup of patients in which anticoagulation therapy with warfarin seems to have an unfavorable risk/benefit ratio as it is less effective at preventing strokes and carries an increased risk of major bleeding [11,12].…”

Section: Introductionmentioning

confidence: 99%

Recent Advances in Stroke Prevention in Patients with Atrial Fibrillation and End-Stage Renal Disease

Ronco¹,

Mazzone

Hosseinian

et al. 2017

Cardiorenal Med

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Background: Chronic kidney disease (CKD) is associated with a high prevalence of atrial fibrillation (AF), but in this population the risk/benefit ratio of anticoagulant therapy with vitamin K antagonists (VKA) for thromboprophylaxis is uncertain. Summary: In end-stage renal disease (ESRD) patients undergoing hemodialysis, VKA seem less effective in stroke prevention than in the general population, with an increased risk of major bleeding. Recently, novel oral anticoagulant agents (NOACs) have proven to be effective for stroke prevention in AF and have demonstrated an improved safety profile compared to VKA. Limited data from post hoc analyses of controlled clinical trials suggest the safe and effective use of NOACs in patients with moderate renal impairment (i.e., estimated glomerular filtration rate, eGFR, between 30 and 50 mL/min). The question still remains whether NOACs can be used in patients with an eGFR <30 mL/min, since there are no studies addressing this subject. In fact, patients with CKD stage 4 and 5 were excluded from controlled clinical trials on anticoagulation therapy for stroke prevention in AF. Left atrial appendage (LAA) occlusion represents a nonpharmacological alternative for stroke prevention in patients with AF who are difficult to manage medically. Preliminary data indicate a similar efficacy and safety profile in patients with CKD compared to patients with normal renal function. Key Messages: Stroke prevention in patients with ESRD and AF represents a clinical challenge with poor evidence. LAA occlusion may become the standard of care for stroke prevention in patients with ESRD and AF.

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Stroke, Major Bleeding, and Mortality Outcomes in Warfarin Users With Atrial Fibrillation and Chronic Kidney Disease

Cited by 212 publications

References 29 publications

Dabigatran etexilate: appropriate use in patients with chronic kidney disease and in the elderly patients

Dabigatran etexilate: appropriate use in patients with chronic kidney disease and in the elderly patients

Profilaktyka powikłań zakrzepowo-zatorowych u chorych z migotaniem przedsionków i przewlekłą chorobą nerek — pozycja nowych doustnych antykoagulantów

Recent Advances in Stroke Prevention in Patients with Atrial Fibrillation and End-Stage Renal Disease

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