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Jones A, Swan D, Lisman T, Barnes GD, Thachil J. Anticoagulation in chronic kidney disease: current status and future perspectives. J Thromb Haemost 2024; 22:323-336. [PMID: 37778512 DOI: 10.1016/j.jtha.2023.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 09/14/2023] [Accepted: 09/21/2023] [Indexed: 10/03/2023]
Abstract
Chronic kidney disease (CKD) is being diagnosed increasingly worldwide. It is often identified in individuals with comorbidities, which may increase the already heightened risk of thrombosis and hemorrhage associated with CKD. Oral anticoagulation is an effective means of reducing rates of ischemic stroke and systemic embolism in patients with atrial fibrillation and minimizes the morbidity and mortality caused by venous thromboembolic disease. Despite the proven benefits in the majority of patients, these have not been so clearly realized in patients with CKD due to the precarious balance between bleeding and thromboembolic complications. In this review, the current status of anticoagulant utilization in CKD is examined, and some practical recommendations are put forward to assist in the decision-making process of safely anticoagulating patients with CKD diagnosed with atrial fibrillation and venous thromboembolism.
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Affiliation(s)
- Alfred Jones
- Department of Haematology, Beaumont Hospital, Dublin, Ireland
| | - Dawn Swan
- Department of Haematology, Beaumont Hospital, Dublin, Ireland.
| | - Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Geoffrey D Barnes
- Division of Cardiovascular Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Oxford Road, Manchester, United Kingdom
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Shen HS, Hsu CY, Yip HT, Lin IH. Lower risk of ischemic stroke among patients with chronic kidney disease using chinese herbal medicine as add-on therapy: A real-world nationwide cohort study. Front Pharmacol 2022; 13:883148. [PMID: 36034816 PMCID: PMC9403506 DOI: 10.3389/fphar.2022.883148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 07/11/2022] [Indexed: 11/13/2022] Open
Abstract
Background: The incidence of ischemic stroke (IS) is much higher among patients with chronic kidney disease (CKD) compared to the general population. Few studies have evaluated the association between the risk of IS and the use of Chinese herbal medicine (CHM) in patients with CKD. We aimed to investigate the risk of IS among patients with CKD using CHM as add-on therapy.Methods: We conducted a retrospective cohort study based on Taiwan’s National Health Insurance Research Database to assess 21,641 patients with newly diagnosed CKD between 2003 and 2012. Patients were classified as either the CHM (n = 3,149) or the non-CHM group (n = 3,149) based on whether they used CHM after first diagnosis of CKD. We used the proportional subdistribution hazards model of Fine and Gray to examine the hazard ratio (HR) of IS in propensity-score matched samples at a ratio of 1:1 for two groups.Results: The risk of IS was significantly reduced in the CHM group (adjusted HR [aHR]: 0.58, 95% confidence interval [CI]: 0.48–0.70) compared with the non-CHM group. Those who used CHM for >180 days had an even lower risk of IS than those in the non-CHM group (aHR: 0.51, 95% CI: 0.41–0.63). Additionally, frequently prescribed formulae, such as Ji-Sheng-Shen-Qi-Wan, Liu-Wei-Di-Huang-Wan, and Zhen-Wu-Tang were associated with a 30%–50% reduced risk of IS.Conclusion: Our results suggest that patients with CKD who used CHM as add-on therapy had a lower hazard of IS than those in the non-CHM group, especially for patients taking CHM for >180 days. Further experimental studies are required to clarify the causal relationship.
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Affiliation(s)
- Hsuan-Shu Shen
- Department of Chinese Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Hualien, Taiwan
- Sports Medicine Center, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
| | - Chung-Yi Hsu
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
| | - Hei-Tung Yip
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
| | - I-Hsin Lin
- School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Hualien, Taiwan
- Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
- *Correspondence: I-Hsin Lin,
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Reyes JL, Herzog CA, Yan H, Roetker NS, Wetmore JB. Prescribing Patterns of Direct-Acting Oral Anticoagulants in Patients With Atrial Fibrillation and Chronic Kidney Disease: A Retrospective Cohort Analysis. J Cardiovasc Pharmacol Ther 2022; 27:10742484221142220. [PMID: 36472155 DOI: 10.1177/10742484221142220] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The association of patient and prescriber characteristics with use of warfarin versus direct-acting oral anticoagulants (DOACs) in patients with atrial fibrillation (AF) and chronic kidney disease (CKD) is not well studied. METHODS The 20% Centers for Medicare & Medicaid Services Parts A, B, and D claims data from 2010 to 2017 were used to identify patients with stage 3, 4, or 5 CKD and AF who received a DOAC (apixaban, dabigatran, rivaroxaban) or warfarin. Prescribers were categorized as cardiologists, primary care providers (PCPs), and others. Using logistic regression, we estimated odds ratios (ORs) for the association of baseline characteristics and prescriber specialty with first use of a DOAC, relative to warfarin. RESULTS We identified 22,739 individuals with CKD who were newly initiated on oral anticoagulation for AF. New DOAC prescriptions increased from 490 in 2011 to 3261 in 2017, and displaced warfarin over time (1849, 2011; 945, 2017). By Q4 of 2014, cardiologists prescribed DOACs as initial treatment more frequently than warfarin, but non-cardiologists did not do so until 2015. As of 2017, apixaban was the most widely prescribed anticoagulant, comprising 56% and 50% of prescriptions by cardiologists and non-cardiologists, respectively. PCPs (OR 0.54, 0.51-0.58) and other providers (OR 0.55, 0.51-0.59) were less likely than cardiologists to prescribe DOACs. CONCLUSIONS DOAC prescriptions, particularly apixaban, increased over time and gradually displaced warfarin. The total number of patients with AF and CKD receiving anticoagulation increased over time. Cardiologists increased DOAC prescriptions more rapidly than non-cardiologists.
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Affiliation(s)
- Jorge L Reyes
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Charles A Herzog
- Division of Cardiology, Hennepin County Medical Center, Minneapolis, MN, USA.,Department of Medicine, University of Minnesota, Minneapolis, MN, USA.,Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Heng Yan
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Nicholas S Roetker
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - James B Wetmore
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA.,Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA.,Division of Nephrology, Hennepin County Medical Center, Minneapolis, MN, USA
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Rashid N, Wetmore JB, Irfan M, Abler V. Adverse Outcomes Associated With Off-Label Agents Used to Treat Dementia Patients With Psychosis: A Case-Control Medicare Database Study. Am J Alzheimers Dis Other Demen 2022; 37:15333175221081374. [PMID: 35331005 PMCID: PMC10623966 DOI: 10.1177/15333175221081374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Currently, there are no Food and Drug Administration-approved therapies to treat dementia-related psychosis (DRP). This study investigated the association between using antipsychotics and the anticonvulsant divalproex (sodium valproate) to manage DRP and adverse outcomes. METHODS A retrospective case/control matching study evaluated the risk of mortality, extrapyramidal symptoms (EPS), ischemic stroke, and cardiac arrest/ventricular arrhythmia (CA/VA) with ever-use of antipsychotics/divalproex in patients with DRP vs never-use. RESULTS 49 509 patients were included; 76.8% used an antipsychotic/divalproex. Treatment ever-use was associated with an increased risk of all-cause mortality (odds ratio, 1.14; 95% CI, 1.10-1.18) and a smaller increase in the risk of EPS (1.10; 1.00-1.19) relative to never-use (adjusted for matching demographic variables, comorbid conditions, and disability). CONCLUSIONS Current agents used for DRP were associated with increased risk of death and adverse outcomes. An increased risk of death was evident within 3 months of antipsychotic/divalproex initiation and persisted with long-term use.
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Affiliation(s)
| | - James B. Wetmore
- Division of Nephrology, Hennepin County Medical Center, Minneapolis, MN, USA
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Muna Irfan
- University of Minnesota and Veterans Affairs Medical Center, Minneapolis, MN, USA
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Mark PB, Jhund PS, Walters MR, Petrie MC, Power A, White C, Robertson M, Connolly E, Anker SD, Bhandari S, Farrington K, Kalra PA, Tomson CR, Wheeler DC, Winearls CG, McMurray JJ, Macdougall IC, Ford I. Stroke in Hemodialysis Patients Randomized to Different Intravenous Iron Strategies: A Prespecified Analysis from the PIVOTAL Trial. KIDNEY360 2021; 2:1761-1769. [PMID: 35372992 PMCID: PMC8785850 DOI: 10.34067/kid.0004272021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 09/02/2021] [Indexed: 02/07/2023]
Abstract
Background People with kidney failure treated with hemodialysis (HD) are at increased risk of stroke compared with similarly aged people with normal kidney function. One concern is that treatment of renal anemia might increase stroke risk. We studied risk factors for stroke in a prespecified secondary analysis of a randomized, controlled trial of intravenous iron treatment strategies in HD. Methods We analyzed data from the Proactive IV Iron Therapy in Haemodialysis Patients (PIVOTAL) trial, focusing on variables associated with risk of stroke. The trial randomized 2141 adults who had started HD <12 months earlier and who were receiving an erythropoiesis-stimulating agent (ESA) to high-dose IV iron administered proactively or low-dose IV iron administered reactively in a 1:1 ratio. Possible stroke events were independently adjudicated. We performed analyses to identify variables associated with stroke during follow-up and assessed survival following stroke. Results During a median 2.1 years of follow-up, 69 (3.2%) patients experienced a first postrandomization stroke. Fifty-seven (82.6%) were ischemic strokes, and 12 (17.4%) were hemorrhagic strokes. There were 34 postrandomization strokes in the proactive arm and 35 postrandomization strokes in the reactive arm (hazard ratio, 0.90; 95% confidence interval, 0.56 to 1.44; P=0.66). In multivariable models, women, diabetes, history of prior stroke at baseline, higher baseline systolic BP, lower serum albumin, and higher C-reactive protein were independently associated with stroke events during follow-up. Hemoglobin, total iron, and ESA dose were not associated with risk of stroke. Fifty-eight percent of patients with a stroke event died during follow-up compared with 23% without a stroke. Conclusions In patients on HD, stroke risk is broadly associated with risk factors previously described to increase cardiovascular risk in this population. Proactive intravenous iron does not increase stroke risk.Clinical Trial registry name and registration number: Proactive IV Iron Therapy in Haemodialysis Patients (PIVOTAL), 2013-002267-25.
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Affiliation(s)
- Patrick B. Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Pardeep S. Jhund
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Matthew R. Walters
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Mark C. Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Albert Power
- Richard Bright Renal Unit, North Bristol NHS Trust, Bristol, United Kingdom
| | - Claire White
- Department of Renal Medicine, King's College Hospital, London, United Kingdom
| | - Michele Robertson
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, United Kingdom
| | - Eugene Connolly
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Stefan D. Anker
- Hull and East Yorkshire Hospitals NHS Trust and Hull York Medical School, Hull, United Kingdom
| | - Sunil Bhandari
- Department of Cardiology, Berlin–Brandenburg Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Philip A. Kalra
- Salford Royal Hospital and University of Manchester, Manchester, United Kingdom
| | - Charles R.V. Tomson
- Department of Renal Medicine, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - David C. Wheeler
- Department of Renal Medicine, University College London, London, United Kingdom
| | - Christopher G. Winearls
- Oxford Kidney Unit, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - John J.V. McMurray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Iain C. Macdougall
- Department of Renal Medicine, King's College Hospital, London, United Kingdom
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, United Kingdom
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Kelly DM, Ademi Z, Doehner W, Lip GYH, Mark P, Toyoda K, Wong CX, Sarnak M, Cheung M, Herzog CA, Johansen KL, Reinecke H, Sood MM. Chronic Kidney Disease and Cerebrovascular Disease: Consensus and Guidance From a KDIGO Controversies Conference. Stroke 2021; 52:e328-e346. [PMID: 34078109 DOI: 10.1161/strokeaha.120.029680] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The global health burden of chronic kidney disease is rapidly rising, and chronic kidney disease is an important risk factor for cerebrovascular disease. Proposed underlying mechanisms for this relationship include shared traditional risk factors such as hypertension and diabetes, uremia-related nontraditional risk factors, such as oxidative stress and abnormal calcium-phosphorus metabolism, and dialysis-specific factors such as cerebral hypoperfusion and changes in cardiac structure. Chronic kidney disease frequently complicates routine stroke risk prediction, diagnosis, management, and prevention. It is also associated with worse stroke severity, outcomes and a high burden of silent cerebrovascular disease, and vascular cognitive impairment. Here, we present a summary of the epidemiology, pathophysiology, diagnosis, and treatment of cerebrovascular disease in chronic kidney disease from the Kidney Disease: Improving Global Outcomes Controversies Conference on central and peripheral arterial disease with a focus on knowledge gaps, areas of controversy, and priorities for research.
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Affiliation(s)
- Dearbhla M Kelly
- Wolfson Center for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, United Kingdom (D.M.K.)
| | - Zanfina Ademi
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia (Z.A.)
| | - Wolfram Doehner
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), and Department of Cardiology (Virchow Klinikum), German Centre for Cardiovascular Research (DZHK), Partner Site Berlin and Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Germany (W.D.)
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, United Kingdom (G.Y.H.L.)
| | - Patrick Mark
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, United Kingdom (P.M.)
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (K.T.)
| | - Christopher X Wong
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia (C.X.W.)
| | - Mark Sarnak
- Division of Nephrology, Tufts Medical Center, Boston, MA (M.S.)
| | - Michael Cheung
- Kidney Disease: Improving Global Outcomes, Brussels, Belgium (M.C.)
| | | | - Kirsten L Johansen
- Division of Nephrology, Hennepin County Medical Center, Minneapolis, MN (K.L.J.)
| | - Holger Reinecke
- Department of Cardiology I, University Hospital Münster, Germany (H.R.)
| | - Manish M Sood
- Ottawa Hospital Research Institute, Department of Medicine, The Ottawa Hospital, Civic Campus, ON, Canada (M.M.S.)
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