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AlTurki A, Marafi M, Dawas A, Joza J, Proietti R, Russo V, Mavrakanas T, Trinh E, Weber C, Suri R, Essebag V, Huynh T. Meta-analysis evaluating apixaban in patients with atrial fibrillation and end-stage renal disease requiring dialysis. J Arrhythm 2024; 40:440-447. [PMID: 38939758 PMCID: PMC11199838 DOI: 10.1002/joa3.13051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 04/13/2024] [Accepted: 04/21/2024] [Indexed: 06/29/2024] Open
Abstract
Background Warfarin is considered the primary oral anticoagulant for patients with atrial fibrillation and end-stage renal disease (ESRD) requiring dialysis. Although warfarin can offer significant stroke prevention in this population, the accompanying major bleeding risks make warfarin nearly prohibitive. Apixaban was shown to be superior to warfarin in preventing stroke or systemic embolism, with a lower risk of bleeding and mortality in a large, randomized trial of individuals with mostly normal renal function but none with ESRD. Methods We systematically reviewed evidence comparing apixaban versus warfarin for atrial fibrillation in this population, and evaluated outcomes of stroke or systemic embolism, and major bleeding using random-effects models. The main safety outcome was major bleeding, and the main effectiveness outcome was stroke or systemic embolism. Results We found five observational studies of 10 036 patients (2638 receiving apixaban, and 7398 receiving warfarin) meeting inclusion criteria. Pooled analysis demonstrated a significant reduction in major bleeding with apixaban as compared to warfarin (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.42-0.61; p < .0001). Apixaban was also associated with a reduction in intracranial bleeding (OR 0.58, 95% CI 0.37-0.92; p = .02) and in gastrointestinal bleeding (OR 0.61, 95% CI 0.51-0.73; p < .0001). Furthermore, apixaban was associated with a reduction in stroke/systemic embolism (OR 0.64, 95% CI 0.50-0.82; p < .0001). Conclusion Apixaban was associated with superior outcomes and reduced adverse events compared to warfarin in observational studies of patients with atrial fibrillation on dialysis. Randomized controlled studies are needed to confirm these findings.
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Affiliation(s)
- Ahmed AlTurki
- Division of CardiologyMcGill University Health CenterMontrealQuebecCanada
| | - Mariam Marafi
- Department of NeurologyMontreal Neurological InstituteMontrealQuebecCanada
| | - Ahmed Dawas
- Division of CardiologyMcGill University Health CenterMontrealQuebecCanada
| | - Jacqueline Joza
- Division of CardiologyMcGill University Health CenterMontrealQuebecCanada
| | - Riccardo Proietti
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool and Liverpool Heart & Chest HospitalLiverpoolUK
| | - Vincenzo Russo
- University of Campania “Luigi Vanvitelli”–Monaldi HospitalNaplesItaly
| | - Thomas Mavrakanas
- Division of NephrologyMcGill University Health CenterMontrealQuebecCanada
| | - Emilie Trinh
- Division of NephrologyMcGill University Health CenterMontrealQuebecCanada
| | - Catherine Weber
- Division of NephrologyMcGill University Health CenterMontrealQuebecCanada
| | - Rita Suri
- Division of NephrologyMcGill University Health CenterMontrealQuebecCanada
| | - Vidal Essebag
- Division of CardiologyMcGill University Health CenterMontrealQuebecCanada
| | - Thao Huynh
- Division of CardiologyMcGill University Health CenterMontrealQuebecCanada
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2
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Defoe K, Wichart J, Leung K. Time in Therapeutic Range Using a Nomogram for Dose Adjustment of Warfarin in Patients on Hemodialysis With Atrial Fibrillation. Can J Kidney Health Dis 2021; 8:20543581211046079. [PMID: 34552757 PMCID: PMC8450544 DOI: 10.1177/20543581211046079] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 08/03/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Patients treated with hemodialysis and prescribed warfarin typically have lower time in therapeutic range (TTR) compared to the general population. This may result in less benefit or increased risk of over anticoagulation in these patients. Objective: To assess effectiveness of use of an electronic nomogram for the management of warfarin therapy in patients treated with hemodialysis. Design: Retrospective chart review. Setting: Adult patients treated with hemodialysis. Patients: Patients on hemodialysis receiving warfarin for the management of atrial fibrillation (AF) with therapy managed by nursing led electronic nomogram. Measurements: Time in therapeutic range (as fraction and Rosendaal). Methods: Retrospective chart review over 1 year of international normalized ratio (INR) results was completed, and TTR was calculated. Comparison of patients with TTR greater than 60% to those less than 60% was completed using chi-square analysis. Results: Of 43 patients with warfarin therapy managed by the nomogram, the mean TTR was 55.2% (calculated by fraction method) or 61.2% (calculated by Rosendaal method). More than half of the patients (63.5%) had moderate to good control, defined as TTR greater than 60%. Female sex, liver disease, or history of substance use and more medication holds were associated with lower TTR. Limitations: Small sample size and retrospective nature of review. Conclusions: The results of this review supports the use of an electronic, nursing-led nomogram for the maintenance management of warfarin therapy in stable patients treated with hemodialysis, as use results in TTR greater than 60% for more than half of patients.
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Affiliation(s)
- Kimberly Defoe
- Alberta Health Services - Department of Pharmacy, Calgary, AB, Canada
| | - Jenny Wichart
- Alberta Health Services - Department of Pharmacy, Calgary, AB, Canada
| | - Kelvin Leung
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
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3
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Starr JA, Pinner NA, Mannis M, Stuart MK. A Review of Direct Oral Anticoagulants in Patients With Stage 5 or End-Stage Kidney Disease. Ann Pharmacother 2021; 56:691-703. [PMID: 34459281 DOI: 10.1177/10600280211040093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the role of oral anticoagulation in patients with stage 5 chronic kidney disease (CKD-5) or end-stage kidney disease (ESKD). DATA SOURCES A literature search of PubMed (January 2000 to July 1, 2021), the Cochrane Library, and Google Scholar databases (through April 1, 2021) was performed with keywords DOAC (direct-acting oral anticoagulant) OR NOAC or dabigatran OR rivaroxaban OR apixaban OR edoxaban AND end-stage kidney disease combined with atrial fibrillation (AF) or venous thromboembolism (VTE) OR pulmonary embolism OR deep-vein thrombosis. STUDY SELECTION AND DATA EXTRACTION Case-control, cohort, and randomized controlled trials comparing DOACs to an active control for AF or VTE in patients with CKD-5 or ESKD and reporting outcomes of stroke, recurrent thromboembolism, or major bleeding were included. DATA SYNTHESIS Nine studies were included. Efficacy data supporting routine use of warfarin or DOACs in CKD-5 or ESKD are limited. Rivaroxaban and apixaban may provide enhanced safety compared to warfarin in patients with AF. Data for VTE are limited to 1 retrospective study. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Because of the paucity of rigorous, prospective studies in CKD-5 or ESKD, OACs should not be broadly used in this population. It is clear that data regarding efficacy of DOACs cannot be reliably and safely extrapolated from the non-ESKD population. Therefore, use of OACs in this population should be individualized. CONCLUSIONS If OACs for stroke prevention with AF are deemed necessary, apixaban or rivaroxaban can be considered. DOACs cannot currently be recommended over warfarin in patients with CKD-5 or ESKD and VTE.
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4
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Shawwa K, Kompotiatis P, Bobart SA, Mara KC, Wiley BM, Jentzer JC, Kashani KB. New-onset atrial fibrillation in patients with acute kidney injury on continuous renal replacement therapy. J Crit Care 2020; 62:157-163. [PMID: 33383309 DOI: 10.1016/j.jcrc.2020.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/21/2020] [Accepted: 12/11/2020] [Indexed: 02/09/2023]
Abstract
PURPOSE The mortality of critically ill patients with acute kidney injury (AKI) who require continuous renal replacement therapy (CRRT) remains high. We assessed the incidence and predictors of new-onset atrial fibrillation (NOAF) in this population and its impact on outcomes. MATERIALS AND METHODS This is a retrospective cohort study of adult intensive care units (ICU) patients who had AKI and received CRRT from December 2006 through November 2015 in a tertiary academic medical center. Cox proportional hazard model was used to evaluate the impact of NOAF on overall mortality. RESULTS Out of 1398 screened patients, NOAF occurred in 193 (14%) cases. NOAF occurring on CRRT was independently associated with an increased hazard of death at follow-up (HR: 1.26; 95% CI: 1.03-1.56), compared to the group who did not have NOAF. In the multivariable analysis using time-dependent covariates, higher potassium (HR 1.24, 95%CI: 1.01-1.54) and bicarbonate (HR 0.95, 95%CI: 0.92-0.98) levels were associated with increased and decreased risk of NOAF on CRRT, respectively. CONCLUSIONS NOAF in critically ill patients with AKI receiving CRRT is common and carries an unfavorable prognosis. Prospective studies are required to elucidate modifiable risk factors for NOAF occurring on CRRT.
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Affiliation(s)
- Khaled Shawwa
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Panagiotis Kompotiatis
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Shane A Bobart
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kristin C Mara
- Department of Health Science Research, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Brandon M Wiley
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
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5
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Wetmore JB, Roetker NS, Yan H, Reyes JL, Herzog CA. Direct-Acting Oral Anticoagulants Versus Warfarin in Medicare Patients With Chronic Kidney Disease and Atrial Fibrillation. Stroke 2020; 51:2364-2373. [DOI: 10.1161/strokeaha.120.028934] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background and Purpose:
The comparative effectiveness of direct-acting oral anticoagulants, compared with warfarin, for risks of stroke/systemic embolism, major bleeding, or death have not been studied in Medicare beneficiaries with atrial fibrillation and nondialysis-dependent chronic kidney disease.
Methods:
Medicare data from 2011 to 2017 were used to identify patients with stages 3, 4, or 5 chronic kidney disease and new atrial fibrillation who received a new prescription for warfarin, apixaban, rivaroxaban, or dabigatran. We estimated marginal hazard ratios with 95% CIs for the association of each direct-acting oral anticoagulant, compared with warfarin, for the outcomes of interest using inverse-probability-of-treatment weighted Cox proportional hazards models in as-treated and intention-to-treat analyses.
Results:
A total of 22 739 individuals met criteria (46.3% warfarin, 29.6% apixaban, 17.2% rivaroxaban, 6.9% dabigatran). Across the groups of anticoagulant users, mean age was 78.4 to 79.0 years; 50.3% to 51.4% were women, and 80.3% to 82.8% had stage 3 chronic kidney disease. In the as-treated analysis, for stroke/systemic embolism, hazard ratios, all compared with warfarin, were 0.70 (0.51–0.96) for apixaban, 0.80 (0.54–1.17) for rivaroxaban, and 1.15 (0.69–1.94) for dabigatran. For major bleeding, analogous hazard ratios were 0.47 (0.37–0.59) for apixaban, 1.05 (0.85–1.30) for rivaroxaban, and 0.95 (0.70–1.31) for dabigatran. There was no difference in the risk of all-cause mortality between the direct-acting oral anticoagulants and warfarin. Results of the intention-to-treat analysis were similar.
Conclusions:
Apixaban, compared with warfarin, was associated with decreased risk of stroke/systemic embolism and major bleeding; risks for both outcomes with rivaroxaban and dabigatran did not differ from risks with warfarin.
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Affiliation(s)
- James B. Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN (J.B.W., N.S.R., H.Y., C.A.H.)
- Division of Nephrology (J.B.W.), Hennepin County Medical Center and Department of Medicine, University of Minnesota, Minneapolis
| | - Nicholas S. Roetker
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN (J.B.W., N.S.R., H.Y., C.A.H.)
| | - Heng Yan
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN (J.B.W., N.S.R., H.Y., C.A.H.)
| | - Jorge L. Reyes
- Department of Internal Medicine, Hennepin County Medical Center, Minneapolis, MN (J.L.R.)
| | - Charles A. Herzog
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN (J.B.W., N.S.R., H.Y., C.A.H.)
- Division of Cardiology (C.A.H.), Hennepin County Medical Center and Department of Medicine, University of Minnesota, Minneapolis
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6
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Zhang L, Steckman DA, Adelstein EC, Schulman-Marcus J, Loka A, Mathew RO, Venditti FJ, Sidhu MS. Oral Anticoagulation for Atrial Fibrillation Thromboembolism Prophylaxis in the Chronic Kidney Disease Population: the State of the Art in 2019. Cardiovasc Drugs Ther 2020; 33:481-488. [PMID: 31165356 DOI: 10.1007/s10557-019-06885-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Atrial fibrillation (AF) is the most common cardiac rhythm disturbance and is associated with increased risk of thromboembolism. Oral anticoagulants are effective at reducing rates of thromboembolism in patients with AF in the general population. Patients with AF and concurrent chronic kidney disease (CKD) have higher risk of thromboembolism and bleeding compared with patients with normal renal function. Among moderate CKD and end-stage renal disease (ESRD) patients on chronic dialysis, the use of oral anticoagulants is controversial. Use of warfarin, while beneficial in non-CKD patients, raises a number of concerns such as increased bleeding risk, labile anticoagulant effect, and calciphylaxis, especially in the ESRD population. The newer direct oral anticoagulant (DOAC) agents have demonstrated comparable efficacy and improved safety profiles compared with coumadin but are not as well studied in the CKD population. This review highlights the efficacy and safety of coumadin and the DOACs for thromboembolism prophylaxis in non-valvular AF patients with CKD.
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Affiliation(s)
- Lane Zhang
- Division of Cardiology, Albany Medical Center, 47 New Scotland Ave, Albany, NY, 12208, USA.
| | - David A Steckman
- Division of Cardiology, Albany Medical Center, 47 New Scotland Ave, Albany, NY, 12208, USA
| | - Evan C Adelstein
- Division of Cardiology, Albany Medical Center, 47 New Scotland Ave, Albany, NY, 12208, USA
| | - Joshua Schulman-Marcus
- Division of Cardiology, Albany Medical Center, 47 New Scotland Ave, Albany, NY, 12208, USA
| | - Alfred Loka
- Division of Cardiology, Albany Medical Center, 47 New Scotland Ave, Albany, NY, 12208, USA
| | - Roy O Mathew
- Division of Nephrology, Albany Medical Center, Albany, NY, USA
| | - Ferdinand J Venditti
- Division of Cardiology, Albany Medical Center, 47 New Scotland Ave, Albany, NY, 12208, USA
| | - Mandeep S Sidhu
- Division of Cardiology, Albany Medical Center, 47 New Scotland Ave, Albany, NY, 12208, USA.,Albany Medical College, Albany, NY, USA
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7
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You X, Zhou Y, Zhang J, Zhou Q, Shi Y, Su Z, Chen C, Shao R, Zhang J. Effects of parathyroid hormone and vitamin D supplementation on stroke among patients receiving peritoneal dialysis. BMC Nephrol 2020; 21:183. [PMID: 32423377 PMCID: PMC7236177 DOI: 10.1186/s12882-020-01817-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Accepted: 04/19/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Continuous ambulatory peritoneal dialysis (CAPD) patients have a high incidence of stroke and commonly have increased parathyroid hormone levels and vitamin D insufficiency. We seek to investigate the incidence of stroke and the role of parathyroid hormone and vitamin D supplementation in stroke risk among CAPD patients. METHODS This study employed a retrospective design. We enrolled a Chinese cohort of 980 CAPD patients who were routinely followed in our department. The demographic and clinical data were recorded at the time of initial CAPD and during follow-up. The included patients were separated into non-stroke and stroke groups. The effects of parathyroid hormone and vitamin D supplementation on stroke in CAPD patients was evaluated. The primary endpoint is defined as the first occurrence of stroke, and composite endpoint events are defined as death or switch to hemodialysis during follow-up. RESULTS A total of 757 eligible CAPD patients with a mean follow-up time of 54.7 (standard deviation, 33) months were included in the study. The median incidence of stroke among our CAPD patients was 18.9 (interquartile range, 15.7-22.1) per 1000 person-years. A significant nonlinear correlation between baseline iPTH and hazard of stroke (p-value of linear association = 0.2 and nonlinear association = 0.002) was observed in our univariate Cox regression analysis, and low baseline iPTH levels (≤150 pg/ml) were associated with an increased cumulative hazard of stroke. Multivariate Cox regression analysis indicated a significant interaction effect between age and iPTH after adjusting for other confounders. Vitamin D supplementation during follow-up was a predictive factor for stroke in our cohort. CONCLUSIONS CAPD patients suffered a high risk of stroke, and lower iPTH levels were significantly correlated with an increased risk of stroke. Nevertheless, vitamin D supplementation may reduce the risk of stroke in these patients.
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Affiliation(s)
- Xiaohan You
- Department of Nephrology, the First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Ouhai District, Wenzhou, 325000, Zhejiang, P. R. China
| | - Ying Zhou
- Department of Nephrology, the First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Ouhai District, Wenzhou, 325000, Zhejiang, P. R. China
| | - Jianna Zhang
- Department of Nephrology, the First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Ouhai District, Wenzhou, 325000, Zhejiang, P. R. China
| | - Qiongxiu Zhou
- Department of Nephrology, the First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Ouhai District, Wenzhou, 325000, Zhejiang, P. R. China
| | - Yanling Shi
- Department of Nephrology, the First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Ouhai District, Wenzhou, 325000, Zhejiang, P. R. China
| | - Zhen Su
- Department of Nephrology, the First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Ouhai District, Wenzhou, 325000, Zhejiang, P. R. China
| | - Chaoshen Chen
- Department of Nephrology, the First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Ouhai District, Wenzhou, 325000, Zhejiang, P. R. China
| | - Rongrong Shao
- Department of Nephrology, the First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Ouhai District, Wenzhou, 325000, Zhejiang, P. R. China
| | - Ji Zhang
- Department of Nephrology, the First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Ouhai District, Wenzhou, 325000, Zhejiang, P. R. China.
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8
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Koziolova NA, Polyanskaya EA, Chernyavina AI, Mironova SV. [Atrial Fibrillation in Patients on Dialysis Therapy: Epidemiology, Prognosis and Choice of Anticoagulant Therapy]. ACTA ACUST UNITED AC 2019; 59:72-83. [PMID: 31849314 DOI: 10.18087/cardio.2019.12.n733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 09/17/2019] [Indexed: 11/18/2022]
Abstract
The review presents data on the prevalence of atrial fibrillation in patients on dialysis therapy. It is shown that dialysis-dependent patients with non-valve atrial fibrillation prognosis is extremely unfavorable, significantly increased risk of death due to both ischemic and hemorrhagic complications. Scales to assess the risk of thromboembolic and hemorrhagic complications in patients with atrial fibrillation on program dialysis are not validated. The lack of data from randomized clinical trials makes it much more difficult to choose anticoagulant therapy in patients with terminal stage of chronic kidney disease on dialysis who have undergone kidney transplantation. Therefore, the need for anticoagulant therapy and the choice of drugs in patients in this category should be made on the basis of a personalized multidisciplinary approach, taking into account comorbid pathology and the patient's preferences.
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Affiliation(s)
- N A Koziolova
- Perm State Medical University named after Acad. E. A. Wagner
| | - E A Polyanskaya
- Perm State Medical University named after Acad. E. A. Wagner
| | - A I Chernyavina
- Perm State Medical University named after Acad. E. A. Wagner
| | - S V Mironova
- Perm State Medical University named after Acad. E. A. Wagner
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9
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Chen Y, Zhan X, Zhao Q, Wei X, Xiao J, Yan C, Zhang W. Serum lipoprotein(a) and risk of hemorrhagic stroke among incident peritoneal dialysis patients: a large study from a single center in China. Ren Fail 2019; 41:800-807. [PMID: 31498021 PMCID: PMC6746282 DOI: 10.1080/0886022x.2019.1659151] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 08/15/2019] [Accepted: 08/16/2019] [Indexed: 11/17/2022] Open
Abstract
Background: This retrospective study investigated whether baseline serum lipoprotein(a) (Lp(a)) may predict subsequent stroke in patients under chronic peritoneal dialysis (PD). Methods: Eight hundred and sixty incident PD patients, treated from 1 November 2005 to 28 February 2017, were enrolled, and followed until discontinuation of PD, death, or 31 May 2017. Hemorrhagic or ischemic stroke was the primary outcome. The population was stratified by baseline serum Lp(a) tertile. The risk of each stroke subtype was analyzed using the Cox proportional hazard models. Adjustments were made for: age; gender; history of stroke and hypertension; systolic blood pressure; lipid-lowering, antiplatelet and antihypertensive medications; laboratory profiles including hemoglobin, serum albumin, calcium, triglyceride, total and low-density lipoprotein cholesterol; and apolipoprotein A1. Results: Among the 860 participants, 19.3% and 4.1% had diabetes mellitus and a history of stroke, respectively. The median baseline serum Lp(a) was 328 (172-585) mg/L. After 28 (14-41) months of follow-up, 33 (3.84%) and 12 (1.40%) patients developed hemorrhagic and ischemic stroke, respectively. Participants in the highest Lp(a) tertile had a significantly lower risk of hemorrhagic stroke compared with those in the lowest tertile (hazard ratio (HR) 0.3, 95% confidence interval (CI) 0.1-0.86; p = .026); the rates of ischemic stroke were comparable among the tertiles. Each 10 mg/L rise in serum Lp(a) was associated with a 2% (95% CI 0.96-1; p = .033) lower risk of hemorrhagic stroke. Conclusions: Among patients with incident PD, a higher serum Lp(a) level may predict a lower risk of hemorrhagic stroke.
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Affiliation(s)
- Yanbing Chen
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiaojiang Zhan
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Qing Zhao
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xin Wei
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jun Xiao
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Caixia Yan
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wei Zhang
- Department of Respiration, The First Affiliated Hospital of Nanchang University, Nanchang, China
- CONTACT Wei Zhang Department of Respiration, The First Affiliated Hospital of Nanchang University, 17# Yongwai Street, Nanchang 330006, China
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10
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Findlay M, MacIsaac R, MacLeod MJ, Metcalfe W, Sood MM, Traynor JP, Dawson J, Mark PB. The Association of Atrial Fibrillation and Ischemic Stroke in Patients on Hemodialysis: A Competing Risk Analysis. Can J Kidney Health Dis 2019; 6:2054358119878719. [PMID: 31632680 PMCID: PMC6767723 DOI: 10.1177/2054358119878719] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 08/02/2019] [Indexed: 12/16/2022] Open
Abstract
Background Stroke is common in patients with end-stage renal disease (ESRD) treated with hemodialysis (HD) and associated with high mortality rate. In the general population, atrial fibrillation (AF) is a major risk factor for stroke and therapeutic anticoagulation is associated with risk reduction, whereas in ESRD the relationship is less clear. Objective The purpose of this study is to demonstrate the influence of AF on stroke rates and probability in those on HD following competing risk analyses. Design A national record linkage cohort study. Setting All renal and stroke units in Scotland, UK. Patients All patients with ESRD receiving HD within Scotland from 2005 to 2013 (follow-up to 2015). Measurements Demographic, clinical, and laboratory data were linked between the Scottish Renal Registry, Scottish Stroke Care Audit, and hospital discharge data. Stroke was defined as a fatal or nonfatal event and mortality derived from national records. Methods Associations for stroke were determined using competing risk models: the cause-specific hazards model and the Fine and Gray subdistribution hazards model accounting for the competing risk of death in models of all stroke, ischemic stroke, and first-ever stroke. Results Of 5502 patients treated with HD with 12 348.6-year follow-up, 363 (6.6%) experienced stroke. The stroke incidence rate was 26.7 per 1000 patient-years. Multivariable regression on the cause-specific hazard for stroke demonstrated age, hazard ratio (HR) (95% confidence interval [CI]) = 1.04 (1.03-1.05); AF, HR (95% CI) = 1.88 (1.25-2.83); prior stroke, HR (95% CI) = 2.29 (1.48-3.54), and diabetes, HR (95% CI) = 1.92 (1.45-2.53); serum phosphate, HR (95% CI) = 2.15 (1.56-2.99); lower body weight, HR (95% CI) = 0.99 (0.98-1.00); lower hemoglobin, HR (95% CI) = 0.88 (0.77-0.99); and systolic blood pressure (BP), HR (95% CI) = 1.01 (1.00-1.02), to be associated with an increased stroke rate. In contrast, the subdistribution HRs obtained following Fine and Gray regression demonstrated that AF, weight, and hemoglobin were not associated with stroke risk. In both models, AF was significantly associated with nonstroke death. Limitations Our analyses derive from retrospective data sets and thus can only describe association not causation. Data on anticoagulant use are not available. Conclusions The incidence of stroke in HD patients is high. The competing risk of "prestroke" mortality affects the relationship between AF and risk of future stroke. Trial designs for interventions to reduce stroke risk in HD patients, such as anticoagulation for AF, should take account of competing risks affecting associations between risk factors and outcomes.
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Affiliation(s)
- Mark Findlay
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, UK
| | - Rachael MacIsaac
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
| | - Mary Joan MacLeod
- Institute of Medical Sciences, University of Aberdeen, Foresterhill, UK.,On Behalf of the Scottish Stroke Care Audit, Information Services Division, Edinburgh, UK
| | - Wendy Metcalfe
- Department of Renal Medicine, Royal Infirmary of Edinburgh, UK.,On Behalf of the Scottish Renal Registry, Information Services Division, Glasgow, UK
| | - Manish M Sood
- Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada
| | - Jamie P Traynor
- The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, UK.,On Behalf of the Scottish Renal Registry, Information Services Division, Glasgow, UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, UK
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, UK
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11
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Abstract
Warfarin is the most commonly prescribed anticoagulant in hemodialysis (HD) patients with nonvalvular atrial fibrillation (NVAF). Recent trends show that Nephrologists are increasingly prescribing novel oral anticoagulants, despite the fact that no randomized clinical trials have been conducted in dialysis patients. Difficulties maintaining international normalized ratio in the therapeutic range, increased risk of intracranial hemorrhage and concerns regarding warfarin-induced vascular calcification and calciphylaxis may be responsible. Anticoagulation quality is poor in HD patients. A variety of factors contribute to this: increased antibiotic exposure; comorbid illness; decreased adherence and vitamin K deficiency. Attempts to address this with standardized protocols have been uniformly unsuccessful. In nonadherent patients, thrice weekly observed therapy improved quality. Low-dose vitamin K supplementation improves time in the therapeutic range (TTR) in those with normal kidney function and should be studied in HD patients given their high frequency of vitamin K deficiency. Vascular and valvular calcification associated with warfarin could result from reduced carboxylation of matrix Gla protein (MGP), a well-known inhibitor of vascular calcification. Multiple observational studies also link calciphylaxis to warfarin; warfarin-induced hypercoagulability and decreased carboxylation of MGP could explain this. A large observational study, two meta-analyses, and a systematic review in HD patients with NVAF showed reduced bleeding with apixaban compared to warfarin with similar efficacy in reducing stroke and systemic embolism. Given these results, apixaban is a reasonable alternative to warfarin for anticoagulation of HD patients with NVAF, especially in those with low TTR, until data from randomized clinical trials become available.
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Affiliation(s)
- Robert F Reilly
- Division of Nephrology, Department of Internal Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama.,Division of Nephrology, Medical Service, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
| | - Nishank Jain
- Division of Nephrology, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas.,Medicine Service, Central Arkansas Veterans Affairs Health Care System, Little Rock, Arkansas
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12
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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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13
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Airy M, Schold JD, Jolly SE, Arrigain S, Bansal N, Winkelmayer WC, Nally JV, Navaneethan SD. Cause-Specific Mortality in Patients with Chronic Kidney Disease and Atrial Fibrillation. Am J Nephrol 2018; 48:36-45. [PMID: 30048961 DOI: 10.1159/000491023] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 06/09/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is associated with death in patients with chronic kidney disease (CKD). We examined the associations between AF and cause-specific mortality in a large CKD population. METHODS We included 62,459 patients with estimated glomerular filtration rate 15-59 mL/min/1.73 m2 (6,639 patients with AF and 55,820 without AF) followed in a large health care system. Outcomes included overall and cause-specific deaths (a) cardiovascular; (b) malignancy; and (c) non-cardiovascular/non-malignancy causes. Cox regression models for overall mortality and separate competing risk models for each major cause of death category were used to evaluate their respective associations with AF. RESULTS During a median follow-up of 4.1 years, 19,094 patients died; cause of death was known for 18,854 patients. After multivariable adjustment (demographics, comorbidities, relevant laboratory data, medication use, and kidney function), AF was associated with 23% (95% CI 18-29%) higher risk of all-cause mortality, 45% (95% CI 31-61%) higher risk of cardiovascular mortality and 13% (95% CI 3-22%) lower risk of malignancy-related mortality. Exclusion of patients with malignancy yielded similar results except for a lack of association between AF and malignancy-related deaths. Results were consistent across various stages of CKD. CONCLUSIONS In a non-dialysis-dependent CKD population, the presence of AF was associated with higher all-cause and cardiovascular mortality. These data suggest that patients with both CKD and AF are at high cardiovascular risk, and thus clinical practice (or trials) should aim at reducing the overall excess cardiovascular mortality (not stroke alone) in patients with AF and CKD.
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Affiliation(s)
- Medha Airy
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jesse D Schold
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Stacey E Jolly
- Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Susana Arrigain
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nisha Bansal
- Kidney Research Institute, University of Washington, Seattle, Washington, USA
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Joseph V Nally
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sankar D Navaneethan
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
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14
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Implant success and safety of left atrial appendage occlusion in end stage renal disease patients: Peri-procedural outcomes from an Italian dialysis population. Int J Cardiol 2018; 262:38-42. [DOI: 10.1016/j.ijcard.2018.03.083] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 03/09/2018] [Accepted: 03/16/2018] [Indexed: 11/19/2022]
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15
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Uddin LN, Gabitova MA, Sokolova AA, Morozova NS, Napalkov DA, Vychuzhanin DV, Egorov AV, Fomin VV. COMPARISON OF SCHEMES OF PERIOPERATIONAL ANTICOAGULATION IN ATRIAL FIBRILLATION PATIENTS DEMANDING FOR SURGERY. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2018. [DOI: 10.15829/1728-8800-2018-3-71-78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
A literature review provided, on the usage of various schemes of perioperational anticoagulation therapy (ACT) in atrial fibrillation patients undergoing scheduled surgery. It is noted that clinicians quite often pass through a situation when patients taking ACT require invasive investigations and surgery. Perioperational management of such category of patients is complicated as, on the one hand, the surgery under ACT is associated with intraoperational hemorrhagic complications, and, on the other hand, ACT cessation might increase the risk of thrombotic complications. The variants assessed, of different periprocedural ACT in patients taking vitamin K antagonists. It was found that as an alternative to continuous ACT recently, bridge therapy with low molecular weight heparins applied, aiming the decrease of the risk of bleeding in adequate thromboprophylaxis. The results of clinical trials provided on the assessment of bridge therapy in surgery. Risk stratification approaches presents for thromboembolic and hemorrhagic complications in surgery.
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Affiliation(s)
- L. N. Uddin
- I. M. Sechenov First Moscow State Medical University of the Ministry of Health
| | - M. A. Gabitova
- I. M. Sechenov First Moscow State Medical University of the Ministry of Health
| | - A. A. Sokolova
- I. M. Sechenov First Moscow State Medical University of the Ministry of Health
| | - N. S. Morozova
- I. M. Sechenov First Moscow State Medical University of the Ministry of Health
| | - D. A. Napalkov
- I. M. Sechenov First Moscow State Medical University of the Ministry of Health
| | - D. V. Vychuzhanin
- I. M. Sechenov First Moscow State Medical University of the Ministry of Health
| | - A. V. Egorov
- I. M. Sechenov First Moscow State Medical University of the Ministry of Health
| | - V. V. Fomin
- I. M. Sechenov First Moscow State Medical University of the Ministry of Health
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16
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Di Lullo L, Tripepi G, Ronco C, De Pascalis A, Barbera V, Granata A, Russo D, Di Iorio BR, Paoletti E, Ravera M, Fusaro M, Bellasi A. Safety and effectiveness of rivaroxaban and warfarin in moderate-to-advanced CKD: real world data. J Nephrol 2018; 31:751-756. [PMID: 29882198 DOI: 10.1007/s40620-018-0501-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 05/23/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND In recent years, novel anticoagulant drugs have been introduced in the clinical armamentarium and have progressively gained momentum. Although their use is increasing among CKD patients, some skepticism about their risk-benefit ratio still persists. We sought to investigate the safety and effectiveness of rivaroxaban in a cohort of moderate-to-advanced CKD patients. METHODS This observational, retrospective, longitudinal study involved 347 consecutive CKD stage 3b-4 (according to NKF-KDOQI guidelines) patients enrolled from 8 cardiac outpatient clinics between March 2015 and October 2017. All patients received anticoagulation (100 warfarin vs. 247 rivaroxaban) as part of their non-valvular atrial fibrillation management at the attending physician's discretion. Clinical effectiveness (defined as the occurrence of ischemic stroke, venous thromboembolism, or transient ischemic attack) and safety (intracranial hemorrhage, gastrointestinal or other bleeding) were assessed separately. RESULTS Over a mean follow-up period of 16 ± 0.3 months, 25 stroke episodes (15 hemorrhagic, and 10 ischemic) occurred in 24 warfarin treated patients vs. none in the rivaroxaban arm. There were 5 vs. 0 episodes of deep venous thrombosis and 8 vs. 2 major episodes of bleeding in the warfarin and rivaroxaban groups, respectively. In contrast, the proportion of minor episodes of bleeding was similar between groups. CONCLUSION Rivaroxaban seems a safe and effective therapeutic option in CKD stage 3b-4 patients. However, future randomized controlled trials are needed to definitively establish the role of rivaroxaban in CKD patients.
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Affiliation(s)
- Luca Di Lullo
- Department of Nephrology and Dialysis, L. Parodi - Delfino Hospital, Colleferro, Italy.
| | - Giovanni Tripepi
- Research Unit of Reggio Calabria, Institute of Clinical Physiology, National Research Council (IFC-CNR), Reggio Calabria, Italy
| | - Claudio Ronco
- International Renal Research Institute, S. Bortolo Hospital, Vicenza, Italy
| | | | - Vincenzo Barbera
- Department of Nephrology and Dialysis, L. Parodi - Delfino Hospital, Colleferro, Italy
| | - Antonio Granata
- Department of Nephrology and Dialysis, S. Giovanni di Dio Hospital, Agrigento, Italy
| | - Domenico Russo
- Division of Nephrology, Federico II University, Naples, Italy
| | | | - Ernesto Paoletti
- Department of Nephrology and Dialysis, S. Martino Hospital, Genoa, Italy
| | - Maura Ravera
- Department of Nephrology and Dialysis, S. Martino Hospital, Genoa, Italy
| | - Maria Fusaro
- Department of Medicine, University of Padova, Padua, Italy
| | - Antonio Bellasi
- Department of Nephrology and Dialysis, S. Anna Hospital, ASST Lariana, Como, Italy.
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17
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18
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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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19
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Bilha SC, Burlacu A, Siriopol D, Voroneanu L, Covic A. Primary Prevention of Stroke in Chronic Kidney Disease Patients: A Scientific Update. Cerebrovasc Dis 2018; 45:33-41. [PMID: 29316564 DOI: 10.1159/000486016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 12/02/2017] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Although chronic kidney disease (CKD) is an independent risk factor for stroke, official recommendations for the primary prevention of stroke in CKD are generally lacking. SUMMARY We searched PubMed and ISI Web of Science for randomised controlled trials, observational studies, reviews, meta-analyses and guidelines referring to measures of stroke prevention or to the treatment of stroke-associated risk factors (cardiovascular disease in general and atrial fibrillation (AF), arterial hypertension or carotid artery disease in particular) among the CKD population. The use of oral anticoagulation in AF appears safe in non-end stage CKD, but it should be individualized and preferably based on thromboembolic and bleeding stratification algorithms. Non-vitamin K antagonist oral anticoagulants with definite dose adjustment are generally preferred over vitamin K antagonists in mild and moderate CKD and their indications have started being extended to severe CKD and dialysis also. Aspirin, but not clopidogrel, has limited indications for reducing the risk for atherothrombotic events in CKD due to its increased bleeding risk. Carotid endarterectomy has shown promising results for stroke risk reduction in CKD patients with high-grade symptomatic carotid stenosis. The medical treatment of arterial hypertension in CKD often fails to efficiently lower blood pressure values, but recent data regarding the use of interventional procedures such as renal denervation, baroreflex activation therapy or renal artery stenting are encouraging. Key Messages: In the absence of clear guidelines and protocols, primary prevention of stroke in CKD patients remains a subtle art in the hands of the clinicians. Nevertheless, refraining CKD patients from standard therapies often worsens their prognosis.
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Affiliation(s)
- Stefana Catalina Bilha
- Department of Nephrology, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania
| | - Alexandru Burlacu
- Department of Nephrology, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania.,Department of Interventional Cardiology, Cardiovascular Diseases Institute, Iasi, Romania
| | - Dimitrie Siriopol
- Department of Nephrology, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania.,Nephrology Clinic, Dialysis and Renal Transplant Center, "C.I. Parhon" University Hospital, Iasi, Romania
| | - Luminita Voroneanu
- Department of Nephrology, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania.,Nephrology Clinic, Dialysis and Renal Transplant Center, "C.I. Parhon" University Hospital, Iasi, Romania
| | - Adrian Covic
- Department of Nephrology, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania.,Nephrology Clinic, Dialysis and Renal Transplant Center, "C.I. Parhon" University Hospital, Iasi, Romania
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