151
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Blum D, Chan CT. Iatrogenesis Imperfecta Medicamentosa: Adverse Drug Events in Dialysis Patients are Associated with Higher Resource Utilization and Mortality. Am J Nephrol 2019; 47:438-440. [PMID: 29895031 DOI: 10.1159/000489704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 04/30/2018] [Indexed: 11/19/2022]
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152
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Affiliation(s)
- Rachel Kaplan
- Division of Cardiology, Northwestern University, Feinberg School of Medicine, Chicago, IL (R.K., R.P.).,Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, IL (R.K., R.P.)
| | - Rod Passman
- Division of Cardiology, Northwestern University, Feinberg School of Medicine, Chicago, IL (R.K., R.P.).,Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, IL (R.K., R.P.)
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153
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Hu A, Niu J, Winkelmayer WC. Oral Anticoagulation in Patients With End-Stage Kidney Disease on Dialysis and Atrial Fibrillation. Semin Nephrol 2019; 38:618-628. [PMID: 30413255 DOI: 10.1016/j.semnephrol.2018.08.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Patients with end-stage kidney disease (ESKD) have an elevated incidence of atrial fibrillation (AF) and are at increased risk for thromboembolic events. However, these patients are also at increased risk for bleeding and it is unclear whether they benefit from an oral anticoagulant. Point prevalent on July 1, 2015, only ~28% of dialysis patients with AF were on oral anticoagulation. Warfarin was the most commonly used oral anticoagulant, followed by apixaban, while dabigatran and rivaroxaban were rarely used. This article reviews the current evidence regarding each oral anticoagulant especially as they relate to patients with ESKD.
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Affiliation(s)
- Austin Hu
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Jingbo Niu
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX
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154
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155
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Posch F, Ay C, Stöger H, Kreutz R, Beyer-Westendorf J. Longitudinal kidney function trajectories predict major bleeding, hospitalization and death in patients with atrial fibrillation and chronic kidney disease. Int J Cardiol 2019; 282:47-52. [PMID: 30777405 DOI: 10.1016/j.ijcard.2019.01.089] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 12/28/2018] [Accepted: 01/24/2019] [Indexed: 01/29/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD), commonly described by estimated glomerular filtration rate (eGFR), is a frequent comorbidity in patients with atrial fibrillation (AF) and associated with thromboembolic and bleeding complications. Instead of single eGFR measurements, kidney function decline over time may better predict clinical outcomes but this has not been studied so far. METHODS Patients with AF and stage 3/4 CKD were prospectively followed within a primary care electronic database from the United Kingdom (IMS-THIN). The associations between the longitudinal eGFR trajectory of these patients and stroke/systemic embolism, major bleeding, first hospitalization-for-any-cause, and death-from-any-cause were estimated with joint models of longitudinal and time-to-event data. RESULTS 18,240 patients were included (median age 80.4 years, median CHA2DS2-VASc score 4). In 133,676 eGFR measurements (mean: 6 per patient) median "baseline" eGFR was 49 ml/min/1.73m2 [41-55] and mean eGFR decline was 0.54 ml/min/1.73m2/year (95%CI: 0.47-0.62). During follow-up (median 3.2 years; 50,841 patient-years at risk), 5-year cumulative incidence estimates were 9%, 3%, 32% and 76% for stroke/systemic embolism, major bleeding, hospitalization and death, respectively. In joint modeling, an accelerated decline in kidney function strongly predicted for a higher risk of major bleeding (hazard ratio [HR] 1.09 per ml/min/1.73m2/year increase in eGFR decline), hospitalization (HR 1.06), and death-from-any-cause (HR 1.11; all p < 0.05), but not for stroke/systemic embolism (HR 0.97; p = 0.239). CONCLUSIONS Declining kidney function is a critical determinant of unfavourable outcomes in patients with AF and CKD. Longitudinal kidney function trajectories may enable a much more individualized prediction of adverse outcomes in this vulnerable patient population.
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Affiliation(s)
- Florian Posch
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria; Center for Biomarker Research in Medicine (CBmed), Graz, Austria
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Herbert Stöger
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Reinhold Kreutz
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Institute of Clinical Pharmacology and Toxicology, Germany
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Department of Medicine I, Division of Hematology, University Hospital "Carl Gustav Carus" Dresden, Fetscherstrasse 75, D-01307 Dresden, Germany; King's Thrombosis Service, Department of Hematology, King's College London, UK.
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156
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Garlo KG, Steele DJR, Nigwekar SU, Chan KE. Demystifying the Benefits and Harms of Anticoagulation for Atrial Fibrillation in Chronic Kidney Disease. Clin J Am Soc Nephrol 2018; 14:125-136. [PMID: 30593489 PMCID: PMC6364544 DOI: 10.2215/cjn.06430518] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Patients with CKD represent a vulnerable population where the risks of atrial fibrillation, ischemic stroke, and bleeding are all heightened. Although large randomized, controlled trials in the general population clearly demonstrate that the benefits of warfarin and direct-acting oral anticoagulants outweigh the risks of bleeding, no such studies have been conducted in patients when their creatinine clearance falls below 25-30 ml/min. Without randomized, controlled trial data, the role of anticoagulation in patients with CKD with atrial fibrillation remains unclear and our practice is informed by a growing body of imperfect literature such as observational and pharmacokinetic studies. This article aims to present a contemporary literature review of the benefits versus harms of anticoagulation in atrial fibrillation for patients with CKD stages 3, 4, 5, and 5 on dialysis. Although unanswered questions and areas of clinical equipoise remain, this piece serves to assist physicians in interpreting the complex body of literature and applying it to their clinical care.
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Affiliation(s)
- Katherine G Garlo
- Division of Nephrology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; and
| | - David J R Steele
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Sagar U Nigwekar
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kevin E Chan
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
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157
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Which anticoagulants should be used for stroke prevention in non-valvular atrial fibrillation and severe chronic kidney disease? Curr Opin Nephrol Hypertens 2018; 27:420-425. [DOI: 10.1097/mnh.0000000000000443] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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158
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Alqahtani F, Almustafa A, Shah K, Akram Y, Abbasi D, Rattan R, Subrayappa N, Alkhouli M, Munir MB. Sudden cardiac arrest in end-stage renal disease patients on dialysis: A nationwide study. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:1467-1475. [PMID: 30225901 DOI: 10.1111/pace.13498] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 09/06/2018] [Accepted: 09/09/2018] [Indexed: 01/01/2023]
Affiliation(s)
- Fahad Alqahtani
- Department of Cardiology; West Virginia University Heart and Vascular Institute; Morgantown WV USA
| | - Ahmed Almustafa
- Department of Cardiology; West Virginia University Heart and Vascular Institute; Morgantown WV USA
| | - Kuldeep Shah
- Department of Cardiology; West Virginia University Heart and Vascular Institute; Morgantown WV USA
| | - Yasir Akram
- Department of Cardiology; West Virginia University Heart and Vascular Institute; Morgantown WV USA
| | - Danish Abbasi
- Department of Cardiology; West Virginia University Heart and Vascular Institute; Morgantown WV USA
| | - Rohit Rattan
- Department of Cardiology; Heart and Vascular Institute, University of Pittsburgh Medical Center; Pittsburgh PA USA
| | - Navin Subrayappa
- Department of Cardiology; West Virginia University Heart and Vascular Institute; Morgantown WV USA
| | - Mohamad Alkhouli
- Department of Cardiology; West Virginia University Heart and Vascular Institute; Morgantown WV USA
| | - Muhammad Bilal Munir
- Department of Cardiology; West Virginia University Heart and Vascular Institute; Morgantown WV USA
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159
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160
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Covic A, Genovesi S, Rossignol P, Kalra PA, Ortiz A, Banach M, Burlacu A. Practical issues in clinical scenarios involving CKD patients requiring antithrombotic therapy in light of the 2017 ESC guideline recommendations. BMC Med 2018; 16:158. [PMID: 30227855 PMCID: PMC6145111 DOI: 10.1186/s12916-018-1145-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 08/03/2018] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The choice of the most appropriate antithrombotic regimen that balances ischemic and bleeding risks was addressed by the August 2017 European Society of Cardiologists (ESC)/European Association for Cardio-Thoracic Surgery Focused Update recommendations, which propose new evaluation scores and protocols for patients requiring a coronary stent or patients with an acute coronary syndrome, atrial fibrillation, or a high bleeding risk and indication for oral anticoagulation therapy. DISCUSSION Numerous questions remain regarding antithrombotic regimens and risk management algorithms for both ischemic and hemorrhagic events in patients with chronic kidney disease (CKD) in various clinical scenarios. Limitations of current studies include a general ack of advanced CKD patients in major randomized controlled trials, of evidence on algorithm implementation, and of robust assessment tools for hemorrhagic risk. Herein, we aim to analyze the ESC Update recommendations and the newly implemented risk scores (DAPT, PRECISE-DAPT, PARIS) from the point of view of CKD, providing suggestions on drug choice (which combination has the best evidence), dosage, and duration (the same or different as for non-CKD population) of antithrombotics, as well as to identify current shortcomings and to envision directions of future research. CONCLUSION We provide an evidence-based perspective on the new proposed bleeding management protocol, with focus on the CKD population. Despite previous important steps on antithrombotic therapy of renal patients, there remain many unsolved questions for which our suggestions could fundament new randomized controlled trials and specific protocols.
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Affiliation(s)
- Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center - 'C.I. Parhon' University Hospital, Iasi, Romania.,'Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Simonetta Genovesi
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,Nephrology Unit, San Gerardo Hospital, Monza, Italy
| | - Patrick Rossignol
- Inserm, Centre d'Investigations Cliniques-Plurithématique 14-33, Inserm U1116, CHRU Nancy, Nancy, France.,Université de Lorraine, Association Lorraine de Traitement de l'Insuffisance Rénale (ALTIR) and F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Philip A Kalra
- The University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Stott Lane, Salford, UK
| | - Alberto Ortiz
- IIS-Fundacion Jimenez Diaz UAM, FRIAT and REDINREN, Madrid, Spain
| | - Maciej Banach
- Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Lodz, Poland
| | - Alexandru Burlacu
- Department of Interventional Cardiology, Cardiovascular Diseases Institute, 'Grigore T. Popa' University of Medicine, Iasi, Romania.
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161
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Carrero JJ, Trevisan M, Sood MM, Bárány P, Xu H, Evans M, Friberg L, Szummer K. Incident Atrial Fibrillation and the Risk of Stroke in Adults with Chronic Kidney Disease: The Stockholm CREAtinine Measurements (SCREAM) Project. Clin J Am Soc Nephrol 2018; 13:1314-1320. [PMID: 30030271 PMCID: PMC6140568 DOI: 10.2215/cjn.04060318] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 06/21/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients with CKD have a high risk of atrial fibrillation. Both CKD and atrial fibrillation are associated with higher risk of stroke and death. However, the effect of incident atrial fibrillation on stroke risk among patients with CKD is unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Our study included adults with CKD (eGFR<60 ml/min per 1.73 m2) without previously documented atrial fibrillation who had been in contact with health care in Stockholm, Sweden during 2006-2011. Incident atrial fibrillation was identified by administrative diagnostic codes in outpatient or inpatient care and treated as a time-updated exposure in the analysis of stroke and death risk. Stroke events and deaths were ascertained from regional and national registers with complete coverage. Covariates included demographics, comorbidities, therapeutic procedures, and medications. Multivariable Cox regression analysis and competing risk analysis (accounting for death) were used to estimate the association between incident atrial fibrillation and stroke. RESULTS Among 116,184 adults with CKD, 13,412 (12%) developed clinically recognized atrial fibrillation during a mean follow-up of 3.9 years (interquartile range, 2.3-5.7 years). Incidence of atrial fibrillation increased across lower eGFR strata: from 29.4 to 46.3 atrial fibrillations per 1000 person-years in subjects with eGFR=45-60 and <30 ml/min per 1.73 m2, respectively; 1388 (53.8 per 1000 person-years) cases of stroke and 5592 (205.1 per 1000 person-years) deaths occurred after incident atrial fibrillation compared with 6850 (16.6 per 1000 person-years) cases of stroke and 28,613 (67.5 per 1000 person-years) deaths during periods without atrial fibrillation. After adjustment, incident atrial fibrillation was associated with higher risk of stroke (hazard ratio, 2.00; 95% confidence interval, 1.88 to 2.14) and death (hazard ratio, 1.76; 95% confidence interval, 1.71 to 1.82). This was attributed to both ischemic stroke (hazard ratio, 2.11; 95% confidence interval, 1.96 to 2.28) and intracranial bleeds (hazard ratio, 1.64; 95% confidence interval, 1.42 to 1.90). Stroke risk was similar across all eGFR strata. In competing risk analyses accounting for death, the association between incident atrial fibrillation and stroke was attenuated but remained higher (subhazard ratio, 1.49; 95% confidence interval, 1.39 to 1.60). CONCLUSIONS Patients with CKD who develop atrial fibrillation are at higher risk of stroke and death.
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Affiliation(s)
| | - Marco Trevisan
- Departments of Medical Epidemiology and Biostatistics and
| | - Manish M. Sood
- Division of Nephrology, and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Peter Bárány
- Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Hong Xu
- Departments of Medical Epidemiology and Biostatistics and
| | - Marie Evans
- Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Leif Friberg
- Department of Clinical Sciences, Danderyds Hospital, Stockholm, Sweden; and
| | - Karolina Szummer
- Department of Medicine, Karolinska Institutet, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
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162
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Winkelmayer WC. Mapping Progress in Reducing Cardiovascular Risk with Kidney Disease: Atrial Fibrillation. Clin J Am Soc Nephrol 2018; 13:1423-1425. [PMID: 30111584 PMCID: PMC6140555 DOI: 10.2215/cjn.06270518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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163
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Tereshchenko LG, Posnack NG. Does plastic chemical exposure contribute to sudden death of patients on dialysis? Heart Rhythm 2018; 16:312-317. [PMID: 30144582 DOI: 10.1016/j.hrthm.2018.08.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Indexed: 01/02/2023]
Affiliation(s)
- Larisa G Tereshchenko
- Oregon Health and Science University, Knight Cardiovascular Institute, Portland, Oregon.
| | - Nikki G Posnack
- Children's National Health System, Sheikh Zayed Institute, Heart Institute, Washington, District of Columbia
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164
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Chronic kidney disease and arrhythmias: highlights from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2018; 94:231-234. [DOI: 10.1016/j.kint.2018.05.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 05/16/2018] [Indexed: 11/22/2022]
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165
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Affiliation(s)
- Thomas F Lüscher
- Consultant and Director of Research, Education & Development, Royal Brompton and Harefield Hospital Trust, London, UK.,Chairman, Center for Molecular Cardiology, University of Zurich, Switzerland.,EHJ Editorial Office, Zurich Heart House, Hottingerstreet 14, Zurich, Switzerland
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166
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Chokesuwattanaskul R, Thongprayoon C, Tanawuttiwat T, Kaewput W, Pachariyanon P, Cheungpasitporn W. Safety and efficacy of apixaban versus warfarin in patients with end‐stage renal disease: Meta‐analysis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:878. [PMID: 29791015 DOI: 10.1111/pace.13390] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 05/10/2018] [Indexed: 10/16/2022]
Affiliation(s)
- Ronpichai Chokesuwattanaskul
- Division of Cardiology, Department of Medicine, Faculty of MedicineChulalongkorn University and King Chulalongkorn Memorial Hospital Bangkok Thailand
| | | | - Tanyanan Tanawuttiwat
- Division of Cardiology, Department of MedicineUniversity of Mississippi Medical Center Jackson MS USA
| | - Wisit Kaewput
- Department of Military and Community MedicinePhramongkutklao College of Medicine Bangkok Thailand
| | - Pavida Pachariyanon
- Department of Internal MedicineTexas Tech University Health Sciences Center Lubbock TX USA
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of MedicineUniversity of Mississippi Medical Center Jackson MS USA
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167
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Shroff GR, Stoecker R, Hart A. Non-Vitamin K-Dependent Oral Anticoagulants for Nonvalvular Atrial Fibrillation in Patients With CKD: Pragmatic Considerations for the Clinician. Am J Kidney Dis 2018; 72:717-727. [PMID: 29728318 DOI: 10.1053/j.ajkd.2018.02.360] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 02/22/2018] [Indexed: 01/27/2023]
Abstract
Management of atrial fibrillation (AF) in patients with advanced chronic kidney disease (CKD) poses a complex conundrum because of higher risks for both thromboembolic and bleeding complications compared to the general population. This makes it particularly important for clinicians to carefully weigh the risks versus benefits of anticoagulation therapy to determine the individualized net clinical benefit for every patient. During the past few years, 4 non-vitamin K-dependent oral anticoagulant (NOAC) agents have supplemented warfarin in the therapeutic armamentarium for the prevention of systemic thromboembolism in nonvalvular AF. However, the use of NOACs in CKD specifically mandates a nuanced understanding due to their varying dependence on renal clearance, with resultant safety implications related to either underdosing (thromboembolism) or excessive drug exposure (bleeding). This pragmatic review highlights unique considerations pertaining to accurate estimation and temporal monitoring of kidney function in the context of NOAC use with specific clinical deliberations and variables when determining whether an NOAC is appropriate for a patient with CKD. The dependence of NOACs on renal clearance and several troubling safety signals in the published literature suggest that it is vital for nephrologists to be active members of a multidisciplinary team caring for these high-risk patients with CKD and AF.
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Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Internal Medicine, Hennepin County Medical Center, Minneapolis, MN; University of Minnesota Medical School, Minneapolis, MN.
| | - Rachel Stoecker
- Department of Pharmacy, Hennepin County Medical Center, Minneapolis, MN
| | - Allyson Hart
- Division of Nephrology, Department of Internal Medicine, Hennepin County Medical Center, Minneapolis, MN; University of Minnesota Medical School, Minneapolis, MN
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