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Wu L, Rodriguez M, Hachem KE, Tang WHW, Krittanawong C. Management of patients with heart failure and chronic kidney disease. Heart Fail Rev 2024; 29:989-1023. [PMID: 39073666 DOI: 10.1007/s10741-024-10415-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2024] [Indexed: 07/30/2024]
Abstract
Chronic kidney disease (CKD) and heart failure are often co-existing conditions due to a shared pathophysiological process involving neurohormonal activation and hemodynamic maladaptation. A wide range of pharmaceutical and interventional tools are available to patients with CKD, consisting of traditional ones with decades of experience and newer emerging therapies that are rapidly reshaping the landscape of medical care for this population. Management of patients with heart failure and CKD requires a stepwise approach based on renal function and the clinical phenotype of heart failure. This is often challenging due to altered drug pharmacokinetics interactions with various degrees of kidney function and frequent adverse effects from the therapy that lead to poor patient tolerance. Despite a great body of clinical evidence and guidelines that have offered various treatment options for patients with heart failure and CKD, respectively, patients with CKD are still underrepresented in heart failure clinical trials, especially for those with advanced CKD and end-stage renal disease (ESRD). Future studies are needed to better understand the generalizability of these therapeutic options among heart failures with different stages of CKD.
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Affiliation(s)
- Lingling Wu
- Cardiovascular Division, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mario Rodriguez
- John T Milliken Department of Medicine, Division of Cardiovascular disease, Section of Advanced Heart Failure and Transplant, Barnes-Jewish Hospital, Washington University in St. Louis School of Medicine, St. Louis, USA
| | - Karim El Hachem
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland, Clinic, Cleveland, OH, USA
| | - Chayakrit Krittanawong
- Cardiology Division, Section of Cardiology, NYU Langone Health and NYU School of Medicine, 550 First Avenue, New York, NY, 10016, USA.
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Roh JH, Kim YG, Kim D, Park S, Park KS, Kim M, Hwang KW, Hwang W, Park GM, Lee JH. Direct oral anticoagulants for oral anticoagulants-naïve Asian patients with atrial fibrillation and end-stage renal disease undergoing dialysis. Sci Rep 2024; 14:14679. [PMID: 38918543 PMCID: PMC11199492 DOI: 10.1038/s41598-024-65541-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 06/20/2024] [Indexed: 06/27/2024] Open
Abstract
In Asian patients with atrial fibrillation (AF) and end-stage renal disease (ESRD) undergoing dialysis, the use of direct oral anticoagulants (DOACs) remains debatable. From the national health insurance claims data in South Korea, we included 425 new users of OAC among patients with non-valvular AF and ESRD undergoing dialysis between 2013 and 2020. Patients were categorized into DOAC (n = 106) and warfarin group (n = 319). Clinical outcomes, including ischemic stroke, myocardial infarction (MI), intracranial hemorrhage (ICH), and gastrointestinal (GI) bleeding, were compared between the two groups using inverse probability of treatment weighting (IPTW) analysis. During the median follow-up of 3.2 years, the incidence of ischemic stroke was significantly reduced in the DOAC compared to the warfarin group [Hazard ratio (HR) 0.07; P = 0.001]. However, the incidence of MI (HR 1.32; P = 0.41) and GI bleeding (HR 1.78; P = 0.06) were not significantly different between the two groups. No ICH events occurred in the DOAC group, although the incidence rate did not differ significantly between the two groups (P = 0.17). In Asian patients with AF and ESRD undergoing dialysis, DOACs may be associated with a reduced risk of ischemic stroke compared with warfarin. The MI, ICH, and GI bleeding rates may be comparable between DOACs and warfarin.
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Affiliation(s)
- Jae-Hyung Roh
- Division of Cardiology, Chungnam National University Sejong Hospital, Chungnam National University School of Medicine, Sejong, Korea
| | - Yong-Giun Kim
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea.
| | - Doyeon Kim
- Graduate School of Data Science, Kyungpook National University, Daegu, Korea
| | - Sangwoo Park
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Kyung Sun Park
- Department of Nephrology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Minsu Kim
- Division of Cardiology, Chungnam National University Sejong Hospital, Chungnam National University School of Medicine, Sejong, Korea
| | - Ki Won Hwang
- Division of Cardiology, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan, Korea
| | - Wonmook Hwang
- Division of Cardiology, Chungnam National University Sejong Hospital, Chungnam National University School of Medicine, Sejong, Korea
| | - Gyung-Min Park
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Jae-Hwan Lee
- Division of Cardiology, Chungnam National University Sejong Hospital, Chungnam National University School of Medicine, Sejong, Korea
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Kang SH, Kim GO, Kim BY, Son EJ, Do JY. Clinical Impact of the Use of Warfarin in Patients with Atrial Fibrillation Undergoing Maintenance Hemodialysis. J Clin Med 2024; 13:2404. [PMID: 38673676 PMCID: PMC11051249 DOI: 10.3390/jcm13082404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/15/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
Background: We evaluated the impact of warfarin use on the clinical outcomes of patients with atrial fibrillation who were undergoing hemodialysis (HD). Methods: A retrospective analysis was conducted utilizing data from patients undergoing maintenance HD who participated in HD quality assessment programs. Patients who were assigned the diagnostic code for atrial fibrillation (n = 4829) were included and divided into two groups based on the use of warfarin: No group (no warfarin prescriptions (n = 4009)), and Warfarin group (warfarin prescriptions (n = 820)). Results: Cox regression analyses revealed that the hazard ratio for all-cause mortality in the Warfarin group was 1.15 (p = 0.005) in univariate analysis and 1.11 (p = 0.047) in multivariable analysis compared to that of the No group. Hemorrhagic stroke was significantly associated with warfarin use, but no significant association between the use of warfarin and ischemic stroke or cardiovascular events was observed. The subgroup results demonstrated similar trends. Conclusions: Warfarin use is associated with a higher risk of all-cause mortality and hemorrhagic stroke, and has a neutral effect on ischemic stroke and cardiovascular events in patients with atrial fibrillation who are undergoing HD, compared to those who are not using warfarin.
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Affiliation(s)
- Seok Hui Kang
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea;
| | - Gui Ok Kim
- Healthcare Review and Assessment Committee, Health Insurance Review and Assessment Service, Wonju 26465, Republic of Korea
| | - Bo Yeon Kim
- Quality Assessment Department, Health Insurance Review and Assessment Service, Wonju 26465, Republic of Korea
| | - Eun Jung Son
- Healthcare Review and Assessment Committee, Health Insurance Review and Assessment Service, Wonju 26465, Republic of Korea
| | - Jun Young Do
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea;
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Kao T, Chen Z, Lin Y. Anticoagulation for Patients With Concomitant Atrial Fibrillation and End-Stage Renal Disease: A Systematic Review and Network Meta-Analysis. J Am Heart Assoc 2024; 13:e034176. [PMID: 38606775 PMCID: PMC11262503 DOI: 10.1161/jaha.123.034176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 03/19/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Concomitant atrial fibrillation and end-stage renal disease is common and associated with an unfavorable prognosis. Although oral anticoagulants have been well established to prevent thromboembolism, the applicability in patients under long-term dialysis remains debatable. The study aimed to determine the efficacy and safety of anticoagulation in the dialysis-dependent population. METHODS AND RESULTS An updated network meta-analysis based on MEDLINE, EMBASE, and the Cochrane Library was performed. Studies published up to December 2022 were included. Direct oral anticoagulants (DOACs, dabigatran, rivaroxaban, apixaban 2.5/5 mg twice daily), vitamin K antagonists (VKAs), and no anticoagulation were compared on safety and efficacy outcomes. The outcomes of interest were major bleeding, thromboembolism, and all-cause death. A total of 42 studies, including 3 randomized controlled trials, with 185 864 subjects were pooled. VKAs were associated with a significantly higher risk of major bleeding than either no anticoagulation (hazard ratio [HR], 1.47; 95% CI, 1.34-1.61) or DOACs (DOACs versus VKAs; HR, 0.74 [95% CI, 0.64-0.84]). For the prevention of thromboembolism, the efficacies of VKAs, DOACs, and no anticoagulation were equivalent. Nevertheless, dabigatran and rivaroxaban were associated with fewer embolic events. There were no differences in all-cause death with the administration of VKAs, DOACs, or no anticoagulation. CONCLUSIONS For dialysis-dependent populations, dabigatran and rivaroxaban were associated with better efficacy, while dabigatran and apixaban demonstrated better safety. No anticoagulation was a noninferior alterative, and VKAs were associated with the worst outcomes.
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Affiliation(s)
- Ting‐Wei Kao
- Department of Internal MedicineNational Taiwan University Hospital and National Taiwan University College of MedicineTaipeiTaiwan
| | - Zheng‐Wei Chen
- Department of Internal MedicineNational Taiwan University Hospital and National Taiwan University College of MedicineTaipeiTaiwan
- Department of Internal MedicineNational Taiwan University Hospital Yun‐Lin BranchYun‐LinTaiwan
- Graduate Institute of Clinical Medicine, National Taiwan University HospitalTaipeiTaiwan
| | - Yen‐Hung Lin
- Department of Internal MedicineNational Taiwan University Hospital and National Taiwan University College of MedicineTaipeiTaiwan
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Shen XF, Zhang C, Hu J, Zhang T, Ma B. Anticoagulant drugs for patients with atrial fibrillation on dialysis: a systematic analysis and network meta-analysis. Front Pharmacol 2023; 14:1320939. [PMID: 38161701 PMCID: PMC10755581 DOI: 10.3389/fphar.2023.1320939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 11/27/2023] [Indexed: 01/03/2024] Open
Abstract
Objective: A lack of clarity persists regarding the efficacy and risks associated with direct oral anticoagulants (DOACs) in end-stage renal disease (ESRD) patients with atrial fibrillation (AF) undergoing dialysis, primarily due to limited retrospective studies. Therefore, the objective of this study was to evaluate the existing data and propose a practical protocol for the clinical utilization of DOACs in ESRD patients with AF undergoing dialysis. Methods: PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for clinical studies evaluating DOACs in ESRD patients with AF on dialysis published up to 2 February 2023. DOACs included warfarin, dabigatran, apixaban, edoxaban, and rivaroxaban. The outcomes were mortality, ischemic stroke, hemorrhagic stroke, any stroke, gastrointestinal bleeding, major bleeding, intracranial bleeding, and minor bleeding. Results: Compared with placebo, apixaban (HR = 0.97, 95% CI: 0.88-1.07), rivaroxaban (HR = 0.91, 95% CI: 0.76-1.10), and warfarin (HR = 0.96, 95% CI: 0.90-1.01) did not reduce mortality. Regarding direct comparisons of mortality, the comparisons of warfarin vs. apixaban (HR = 0.99, 95% CI: 0.92-1.06), placebo vs. warfarin (HR = 1.04, 95% CI: 0.99-1.11), and rivaroxaban vs. warfarin (HR = 0.96, 95% CI: 0.80-1.14) did not significantly reduce mortality. Based on the surface under the cumulative ranking curve, rivaroxaban (75.53%), warfarin (62.14%), and apixaban (45.6%) were the most effective interventions for managing mortality, and placebo (16.74%) was the worst. Conclusion: In conclusion, rivaroxaban demonstrated efficacy in reducing mortality and the incidence of ischemic stroke, gastrointestinal bleeding, and intracranial hemorrhage. Dabigatran is recommended for the prevention of hemorrhagic stroke. However, caution should be exercised due to the risk of major bleeding. Warfarin can effectively reduce minor bleeding but does not offer significant protection against gastrointestinal or intracranial bleeding. Apixaban was not recommended for mortality reduction or for preventing ischemic or hemorrhagic strokes. Further research will be necessary to establish specific clinical protocols.
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Affiliation(s)
- Xian-Feng Shen
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, China
- Department of General Surgery, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Chao Zhang
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Jun Hu
- Department of General Surgery, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Tao Zhang
- Department of Neurosurgery, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Bin Ma
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, China
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Kee YK, Jeon HJ, Oh J, Yoo TH, Kang D, Lee J, Shin DH. Direct oral anti-Xa anticoagulants versus warfarin in newly diagnosed atrial fibrillation and CKD: the Korean National Health Insurance Data. Front Med (Lausanne) 2023; 10:1212816. [PMID: 37786900 PMCID: PMC10541953 DOI: 10.3389/fmed.2023.1212816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 08/28/2023] [Indexed: 10/04/2023] Open
Abstract
Introduction Despite the benefits of direct oral anti-Xa anticoagulants (DOACs), the risk-benefit profile of DOAC therapy compared to warfarin therapy in patients with non-valvular atrial fibrillation (AF) and chronic kidney disease (CKD), including end-stage renal disease (ESRD), is uncertain. Methods We conducted a retrospective study using the Korea National Health Insurance Database from 2013 to 2018. We evaluated patients with incident non-valvular AF and CKD. The primary and secondary effectiveness outcomes were ischemic stroke and all-cause mortality. The primary safety outcomes included intracranial hemorrhage, gastrointestinal bleeding, and extracranial or unclassified major bleeding. Results Among the 1,885 patients evaluated, 970 (51.5%) initiated warfarin therapy, and 915 (48.5%) initiated DOAC therapy. During a mean follow-up period of 23.8 months, there were 293 and 214 cases of ischemic stroke and all-cause death, respectively. Kaplan-Meier survival analysis showed significantly lower all-cause mortality in DOAC users than in warfarin users. In multivariate Cox regression analyses, DOAC therapy had a hazard ratio for all-cause mortality of 0.41 (95% CI, 0.30-0.56; p < 0.001) compared to warfarin therapy. Additionally, DOAC therapy significantly reduced intracranial hemorrhage and gastrointestinal bleeding. Discussion Our study demonstrates that DOAC therapy has a better risk-benefit profile than warfarin therapy in patients with AF and CKD. Further well-designed clinical trials are needed to clarify the benefits of DOACs in this patient population.
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Affiliation(s)
- Youn Kyung Kee
- Department of Internal Medicine, College of Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea
- Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Hee Jung Jeon
- Department of Internal Medicine, College of Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea
| | - Jieun Oh
- Department of Internal Medicine, College of Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea
| | - Tae-Hyun Yoo
- Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Dongwoo Kang
- Data Science Team, Hanmi Pharm. Co., Ltd., Seoul, Republic of Korea
| | - Jungkuk Lee
- Data Science Team, Hanmi Pharm. Co., Ltd., Seoul, Republic of Korea
| | - Dong Ho Shin
- Department of Internal Medicine, College of Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea
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7
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Cho MS, Choi HO, Hwang KW, Kim J, Nam GB, Choi KJ. Clinical benefits and risks of anticoagulation therapy according to the degree of chronic kidney disease in patients with atrial fibrillation. BMC Cardiovasc Disord 2023; 23:209. [PMID: 37098477 PMCID: PMC10131393 DOI: 10.1186/s12872-023-03236-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 04/11/2023] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND The clinical benefits and risks of anticoagulation therapy in patients with chronic kidney disease (CKD) are still inconclusive. We describe the outcomes of patients with atrial fibrillation (AF) after anticoagulation therapy according to differences in creatinine clearance (CrCl). We also aimed to determine the patients who could benefit from anticoagulation therapy. METHODS This is a retrospective observational review of patients with AF who were managed at Asan Medical Center (Seoul, Korea) between January 1, 2006, and December 31, 2018. Patients were categorized into groups according to their baseline CrCl by Cockcroft-Gault equation and their outcomes were evaluated (CKD 1, ≥ 90 mL/min; CKD2, 60-89 mL/min; CKD3, 30-59 mL/min; CKD4, 15-29 mL/min; CKD 5, < 15 mL/min). The primary outcome was NACE (net adverse clinical events), defined as a composite of all-cause mortality, thromboembolic events, and major bleeding. RESULTS We identified 12,714 consecutive patients with AF (mean 64.6 ± 11.9 years, 65.3% male, mean CHA2DS2-VASc score 2.4 ± 1.6 points) between 2006 and 2017. In patients receiving anticoagulation therapy (n = 4447, 35.0%), warfarin (N = 3768, 84.7%) was used more frequently than NOACs (N = 673, 15.3%). There was a higher 3-year rate of NACE with renal function deterioration (14.8%, 18.6%, 30.3%, 44.0%, and 48.8% for CKD stages 1-5, respectively).The clinical benefit of anticoagulation therapy was most prominent in patients with CKD 1 (hazard ratio [HR] 0.49, 95% confidence interval [CI] 0.37-0.67), 2 (HR 0.64 CI 0.54-0.76), and 3 (HR 0.64 CI 0.54-0.76), but not in CKD 4 (HR 0.86, CI 0.57-1.28) and 5 (HR 0.81, CI 0.47-1.40). Among patients with CKD, the benefit of anticoagulation therapy was only evident in those with a high risk of embolism (CHA2DS2-VASc score ≥ 4, HR 0.25, CI 0.08-0.80). CONCLUSION Advanced CKD is associated with a higher risk of NACE. The clinical benefit of anticoagulation therapy was reduced with the increasing CKD stage.
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Affiliation(s)
- Min Soo Cho
- Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyung Oh Choi
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, 170, Jomaru-ro, Bucheon-si, Gyeonggi-do, 14584, Republic of Korea.
| | - Ki Won Hwang
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan, Republic of Korea
| | - Jun Kim
- Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Gi-Byoung Nam
- Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kee-Joon Choi
- Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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A systematic review of the efficacy and safety of anticoagulants in advanced chronic kidney disease. J Nephrol 2022; 35:2015-2033. [PMID: 36006608 PMCID: PMC9584987 DOI: 10.1007/s40620-022-01413-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/19/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) have an increased risk of venous thromboembolism (VTE) and atrial fibrillation (AF). Anticoagulants have not been studied in randomised controlled trials with CrCl < 30 ml/min. The objective of this review was to identify the impact of different anticoagulant strategies in patients with advanced CKD including dialysis. METHODS We conducted a systematic review of randomized controlled trials and cohort studies, searching electronic databases from 1946 to 2022. Studies that evaluated both thrombotic and bleeding outcomes with anticoagulant use in CrCl < 50 ml/min were included. RESULTS Our initial search yielded 14,503 papers with 53 suitable for inclusion. RCTs comparing direct oral anticoagulants (DOACs) versus warfarin for patients with VTE and CrCl 30-50 ml/min found no difference in recurrent VTE events (RR 0.68(95% CI 0.42-1.11)) with reduced bleeding (RR 0.65 (95% CI 0.45-0.94)). Observational data in haemodialysis suggest lower risk of recurrent VTE and major bleeding with apixaban versus warfarin. Very few studies examining outcomes were available for therapeutic and prophylactic dose low molecular weight heparin for CrCl < 30 ml/min. Findings for patients with AF on dialysis were that warfarin or DOACs had a similar or higher risk of stroke compared to no anticoagulation. For patients with AF and CrCl < 30 ml/min not on dialysis, anticoagulation should be considered on an individual basis, with limited studies suggesting DOACs may have a preferable safety profile. CONCLUSION Further studies are still required, some ongoing, in patients with advanced CKD (CrCl < 30 ml/min) to identify the safest and most effective treatment options for VTE and AF.
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Akbar MR, Febrianora M, Iqbal M. Warfarin Usage in Patients with Atrial Fibrillation Undergoing Hemodialysis in Indonesian Population. Curr Probl Cardiol 2022; 48:101104. [PMID: 35041867 DOI: 10.1016/j.cpcardiol.2022.101104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/03/2022] [Indexed: 11/16/2022]
Abstract
The data about the efficacy and safety of warfarin usage in atrial fibrillation (AF) in hemodialysis patients is still limited, especially in the Asia population. The population of this study was end-stage renal disease patients with AF who underwent hemodialysis. The design of the study was a retrospective observational cohort that collected the patient data from 2016 to 2019. The Cox regression model was applied to assess the effect of warfarin on the outcomes. We conducted a survival analysis by comparing Kaplan-Meier curves using the log-rank test. We also measured the time in therapeutic range as a quality indicator of warfarin usage. Among 444 hemodialysis patients, 126 patients with AF matched the inclusion criteria, 88 patients completely followed up. Half patients used warfarin. The mean age was 52.2 ± 12.97 years, the mean follow-up duration was 11 ± 10 months. We observed all-cause death in 86.4% of patients, ischemic stroke in 10.2%, and hemorrhagic stroke in 2.3% of patients. There were no significant differences in all-cause death, ischemic stroke, and hemorrhagic stroke. Warfarin use was not associated with a lower rate for death (HR 0.782; 95% CI, 0.494-1.237, P = 0.293) or ischemic stroke (HR 0.435; 95% CI, 0.103-1.846, P = 0.259) or hemorrhagic stroke (HR 0.564; 95% CI, 0.034-9.386, P = 0.689). None of the patients reach the time in the therapeutic range >65%. Our findings suggest that warfarin has no association with mortality, ischemic stroke, and hemorrhagic stroke events rate in atrial fibrillation patients who underwent hemodialysis in the Indonesian population.
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Affiliation(s)
- Mohammad Rizki Akbar
- Department of Cardiology and Vascular Medicine, Hasan Sadikin General Hospital - Universitas Padjadjaran, Bandung, Indonesia.
| | - Mega Febrianora
- Department of Cardiology and Vascular Medicine, Hasan Sadikin General Hospital - Universitas Padjadjaran, Bandung, Indonesia
| | - Mohammad Iqbal
- Department of Cardiology and Vascular Medicine, Hasan Sadikin General Hospital - Universitas Padjadjaran, Bandung, Indonesia
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Chao T, Joung B, Takahashi Y, Lim TW, Choi E, Chan Y, Guo Y, Sriratanasathavorn C, Oh S, Okumura K, Lip GYH. 2021 Focused update of the 2017 consensus guidelines of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation. J Arrhythm 2021; 37:1389-1426. [PMID: 34887945 PMCID: PMC8637102 DOI: 10.1002/joa3.12652] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 10/22/2021] [Indexed: 12/19/2022] Open
Abstract
The consensus of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation (AF) has been published in 2017 which provided useful clinical guidance for cardiologists, neurologists, geriatricians, and general practitioners in Asia-Pacific region. In these years, many important new data regarding stroke prevention in AF were reported. The Practice Guidelines subcommittee members comprehensively reviewed updated information on stroke prevention in AF, and summarized them in this 2021 focused update of the 2017 consensus guidelines of the APHRS on stroke prevention in AF. We highlighted and focused on several issues, including the importance of AF Better Care (ABC) pathway, the advantages of non-vitamin K antagonist oral anticoagulants (NOACs) for Asians, the considerations of use of NOACs for Asian patients with AF with single 1 stroke risk factor beyond gender, the role of lifestyle factors on stroke risk, the use of oral anticoagulants during the "coronavirus disease 2019" (COVID-19) pandemic, etc. We fully realize that there are gaps, unaddressed questions, and many areas of uncertainty and debate in the current knowledge of AF, and the physician's decision remains the most important factor in the management of AF.
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Affiliation(s)
- Tze‐Fan Chao
- Division of CardiologyDepartment of MedicineTaipei Veterans General HospitalTaipeiTaiwan
- Institute of Clinical Medicine, and Cardiovascular Research CenterNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Boyoung Joung
- Division of CardiologyDepartment of Internal MedicineYonsei University College of MedicineSeoulRepublic of Korea
| | - Yoshihide Takahashi
- The Department of Advanced Arrhythmia ResearchTokyo Medical and Dental UniversityTokyoJapan
| | - Toon Wei Lim
- National University Heart CentreNational University HospitalSingaporeSingapore
| | - Eue‐Keun Choi
- Department of Internal MedicineSeoul National University HospitalSeoulRepublic of Korea
| | - Yi‐Hsin Chan
- Microscopy Core LaboratoryChang Gung Memorial HospitalLinkouTaoyuanTaiwan
- College of MedicineChang Gung UniversityTaoyuanTaiwan
- Microscopy Core LaboratoryChang Gung Memorial HospitalLinkouTaoyuanTaiwan
| | - Yutao Guo
- Pulmonary Vessel and Thrombotic DiseaseChinese PLA General HospitalBeijingChina
| | | | - Seil Oh
- Department of Internal MedicineSeoul National University HospitalSeoulRepublic of Korea
| | - Ken Okumura
- Division of CardiologySaiseikai Kumamoto HospitalKumamotoJapan
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool & Liverpool Heart and Chest HospitalLiverpoolUK
- Aalborg Thrombosis Research UnitDepartment of Clinical MedicineAalborg UniversityAalborgDenmark
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Canaud B, Stephens MP, Nikam M, Etter M, Collins A. Multitargeted interventions to reduce dialysis-induced systemic stress. Clin Kidney J 2021; 14:i72-i84. [PMID: 34987787 PMCID: PMC8711765 DOI: 10.1093/ckj/sfab192] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Indexed: 11/13/2022] Open
Abstract
Hemodialysis (HD) is a life-sustaining therapy as well as an intermittent and repetitive stress condition for the patient. In ridding the blood of unwanted substances and excess fluid from the blood, the extracorporeal procedure simultaneously induces persistent physiological changes that adversely affect several organs. Dialysis patients experience this systemic stress condition usually thrice weekly and sometimes more frequently depending on the treatment schedule. Dialysis-induced systemic stress results from multifactorial components that include treatment schedule (i.e. modality, treatment time), hemodynamic management (i.e. ultrafiltration, weight loss), intensity of solute fluxes, osmotic and electrolytic shifts and interaction of blood with components of the extracorporeal circuit. Intradialytic morbidity (i.e. hypovolemia, intradialytic hypotension, hypoxia) is the clinical expression of this systemic stress that may act as a disease modifier, resulting in multiorgan injury and long-term morbidity. Thus, while lifesaving, HD exposes the patient to several systemic stressors, both hemodynamic and non-hemodynamic in origin. In addition, a combination of cardiocirculatory stress, greatly conditioned by the switch from hypervolemia to hypovolemia, hypoxemia and electrolyte changes may create pro-arrhythmogenic conditions. Moreover, contact of blood with components of the extracorporeal circuit directly activate circulating cells (i.e. macrophages-monocytes or platelets) and protein systems (i.e. coagulation, complement, contact phase kallikrein-kinin system), leading to induction of pro-inflammatory cytokines and resulting in chronic low-grade inflammation, further contributing to poor outcomes. The multifactorial, repetitive HD-induced stress that globally reduces tissue perfusion and oxygenation could have deleterious long-term consequences on the functionality of vital organs such as heart, brain, liver and kidney. In this article, we summarize the multisystemic pathophysiological consequences of the main circulatory stress factors. Strategies to mitigate their effects to provide more cardioprotective and personalized dialytic therapies are proposed to reduce the systemic burden of HD.
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Affiliation(s)
- Bernard Canaud
- Montpellier University, Montpellier, France
- Global Medical Office, FMC Deutschland, Bad Homburg, Germany
| | - Melanie P Stephens
- MSL & Medical Strategies for Innovative Therapies, Fresenius Medical Care, Waltham, MA, USA
| | - Milind Nikam
- Global Medical Office, Fresenius Medical Care, Hong Kong
| | - Michael Etter
- Global Medical Office, Fresenius Medical Care, Hong Kong
| | - Allan Collins
- Global Medical Office, Fresenius Medical Care, Waltham, MA, USA
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12
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Kotalczyk A, Ding WY, Wong CF, Rao A, Gupta D, Lip GYH. Atrial Fibrillation in Patients with Chronic Kidney Disease. Cardiol Clin 2021; 39:435-446. [PMID: 34247756 DOI: 10.1016/j.ccl.2021.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
There is a bidirectional relationship between atrial fibrillation (AF) and chronic kidney disease (CKD), with multiple shared risk factors. This article discusses an integrated care approach toward the management of patients with AF, including those with CKD. There is an increasing risk of both ischemic stroke and bleeding with progressive deterioration of renal function, complicating the decision of optimal stroke prevention strategies among patients with AF and CKD. The optimal stroke prevention strategy in patients with AF and severe CKD remains uncertain. An individualized approach incorporating stroke and bleeding risk stratification is needed, especially in those with end-stage renal disease.
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Affiliation(s)
- Agnieszka Kotalczyk
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK; Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, M. Sklodowskiej-Curie 7, Zabrze 41-800, Poland
| | - Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK
| | - Christopher F Wong
- Department of Renal Medicine, Liverpool University Hospital, Prescot Street, Liverpool L7 8XP, UK
| | - Anirudh Rao
- Department of Renal Medicine, Liverpool University Hospital, Prescot Street, Liverpool L7 8XP, UK
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Søndre Skovvej 15, Aalborg 9000, Denmark.
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13
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Kim JH, Noh J, Kim W, Seong H, Kim JH, Lee WJ, Baek Y, Hyun J, Sohn Y, Cho Y, Kim MH, Ahn S, Lee Y, Ahn JY, Jeong SJ, Ku NS, Yeom JS, Kim C, Choi JY. Trends of age-related non-communicable diseases in people living with HIV and comparison with uninfected controls: A nationwide population-based study in South Korea. HIV Med 2021; 22:824-833. [PMID: 34263511 DOI: 10.1111/hiv.13139] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 06/04/2021] [Indexed: 01/25/2023]
Abstract
OBJECTIVES We aim to compare the trends of non-communicable diseases (NCDs) and death among people living with HIV (PLWH) and uninfected controls in South Korea. METHODS We identified PLWH from a nationwide database of all Korean citizens enrolled from 1 January 2004 to 31 December 2016. A control cohort was randomly selected for PLWH by frequency matching for age and sex in a 20:1 ratio. To compare NCD trends between the groups, adjusted incidence rate ratios for outcomes across ages, calendar years and times after HIV diagnosis were calculated. RESULTS We included 14 134 PLWH and 282 039 controls in this study; 58.5% of PLWH and 36.4% of the controls were diagnosed with at least one NCD. The incidence rates of cancers, chronic kidney disease, depression, osteoporosis, diabetes and dyslipidaemia were higher in PLWH than in the controls, whereas those of cardiovascular disease, heart failure, ischaemic stroke and hypertension were lower in PLWH. Relative risks (RRs) for NCDs in PLWH were higher than controls in younger age groups. Trends in the RRs of NCDs tended to increase with the calendar year for PLWH vs. controls and either stabilized or decreased with time after HIV diagnosis. The RR of death from PLWH has decreased with the calendar year, but showed a tendency to rise again after 2014 and was significant at the early stage of HIV diagnosis. CONCLUSIONS Although the RR of each NCD in PLWH showed variable trends compared with that in controls, NCDs in PLWH have been increasingly prevalent.
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Affiliation(s)
- Jung Ho Kim
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Juhwan Noh
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Woojin Kim
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Hye Seong
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Jun Hyoung Kim
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Woon Ji Lee
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - YaeJee Baek
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - JongHoon Hyun
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Yujin Sohn
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Yunsuk Cho
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Moo Hyun Kim
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - SangMin Ahn
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Yongseop Lee
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Jin Young Ahn
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Su Jin Jeong
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Nam Su Ku
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Joon-Sup Yeom
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Changsoo Kim
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Jun Yong Choi
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, South Korea
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14
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Kim JH, Suh J, Lee WJ, Choi H, Kim JD, Kim C, Choi JY, Ko R, Kim H, Lee J, Yeom JS. Modelling the impact of rapid diagnostic tests on Plasmodium vivax malaria in South Korea: a cost-benefit analysis. BMJ Glob Health 2021; 6:bmjgh-2020-004292. [PMID: 33593755 PMCID: PMC7888375 DOI: 10.1136/bmjgh-2020-004292] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/21/2020] [Accepted: 01/11/2021] [Indexed: 02/03/2023] Open
Abstract
Background Rapid diagnostic tests (RDTs) are widely used for diagnosing Plasmodium vivax malaria, especially in resource-limited countries. However, the impact of RDTs on P. vivax malaria incidence and national medical costs has not been evaluated. We assessed the impact of RDT implementation on P. vivax malaria incidence and overall medical expenditures in South Korea and performed a cost–benefit analysis from the payer’s perspective. Methods We developed a dynamic compartmental model for P. vivax malaria transmission in South Korea using delay differential equations. Long latency and seasonality were incorporated into the model, which was calibrated to civilian malaria incidences during 2014–2018. We then estimated averted malaria cases and total medical costs from two diagnostic scenarios: microscopy only and both microscopy and RDTs. Medical costs were extracted based on data from a hospital in an at-risk area for P. vivax malaria and were validated using Health Insurance Review and Assessment Service data. We conducted a cost–benefit analysis of RDTs using the incremental benefit:cost ratio (IBCR) considering only medical costs and performed a probabilistic sensitivity analysis to reflect the uncertainties of model parameters, costs and benefits. Results The results showed that 55.3% of new P. vivax malaria cases were averted, and $696 214 in medical costs was saved over 10 years after RDT introduction. The estimated IBCR was 2.5, indicating that RDT implementation was beneficial, compared with microscopy alone. The IBCR was sensitive to the diagnosis time reduction, infectious period and short latency period, and provided beneficial results in a benefit over $10.6 or RDT cost under $39.7. Conclusions The model simulation suggested that RDTs could significantly reduce P. vivax malaria incidence and medical costs. Moreover, cost–benefit analysis demonstrated that the introduction of RDTs was beneficial over microscopy alone. These results support the need for widespread adoption of RDTs.
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Affiliation(s)
- Jung Ho Kim
- Department of Internal Medicine, AIDS Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Jiyeon Suh
- School of Mathematics and Computing (Computational Science and Engineering), Yonsei University, Seoul, South Korea
| | - Woon Ji Lee
- Department of Internal Medicine, AIDS Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Heun Choi
- Department of Internal Medicine, National Health Insurance Service Ilsan hospital, Goyang, South Korea
| | - Jong-Dae Kim
- Department of General Surgery, Bestian Woosong Hospital, Daejeon, South Korea
| | - Changsoo Kim
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Jun Yong Choi
- Department of Internal Medicine, AIDS Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Ryeojin Ko
- Department of Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, South Korea
| | - Heewon Kim
- Department of Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, South Korea
| | - Jeehyun Lee
- School of Mathematics and Computing, Yonsei University, Seoul, South Korea
| | - Joon Sup Yeom
- Department of Internal Medicine, AIDS Research Institute, Yonsei University College of Medicine, Seoul, South Korea
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15
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van Oosten MJM, Logtenberg SJJ, Edens MA, Hemmelder MH, Jager KJ, Bilo HJG, Stel VS. Health claims databases used for kidney research around the world. Clin Kidney J 2021; 14:84-97. [PMID: 33564408 PMCID: PMC7857833 DOI: 10.1093/ckj/sfaa076] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 04/07/2020] [Indexed: 12/16/2022] Open
Abstract
Health claims databases offer opportunities for studies on large populations of patients with kidney disease and health outcomes in a non-experimental setting. Among others, their unique features enable studies on healthcare costs or on longitudinal, epidemiological data with nationwide coverage. However, health claims databases also have several limitations. Because clinical data and information on renal function are often lacking, the identification of patients with kidney disease depends on the actual presence of diagnosis codes only. Investigating the validity of these data is therefore crucial to assess whether outcomes derived from health claims data are truly meaningful. Also, one should take into account the coverage and content of a health claims database, especially when making international comparisons. In this article, an overview is provided of international health claims databases and their main publications in the area of nephrology. The structure and contents of the Dutch health claims database will be described, as well as an initiative to use the outcomes for research and the development of the Dutch Kidney Atlas. Finally, we will discuss to what extent one might be able to identify patients with kidney disease using health claims databases, as well as their strengths and limitations.
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Affiliation(s)
- Manon J M van Oosten
- Department of Medical Informatics, Amsterdam UMC, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Mireille A Edens
- Diabetes Research Center and Department of Epidemiology and Statistics, Isala Hospital, Zwolle, The Netherlands
| | - Marc H Hemmelder
- Dutch Renal Registry (Renine), Nefrovisie Foundation, Utrecht, The Netherlands
- Department of Internal Medicine, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Kitty J Jager
- Department of Medical Informatics, Amsterdam UMC, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Henk J G Bilo
- Diabetes Research Center and Department of Epidemiology and Statistics, Isala Hospital, Zwolle, The Netherlands
- Department of Internal Medicine, University Medical Center, Groningen, The Netherlands
- Faculty of Medicine, Groningen University, Groningen, The Netherlands
| | - Vianda S Stel
- Department of Medical Informatics, Amsterdam UMC, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands
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16
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Lee YH, Chen YT, Chang CC, Hsu CY, Su YW, Li SY, Huang CC, Leu HB, Huang PH, Chen JW, Lin SJ. Risk of ischemic stroke in patients with end-stage renal disease receiving peritoneal dialysis with new-onset atrial fibrillation. J Chin Med Assoc 2020; 83:1066-1070. [PMID: 32858549 DOI: 10.1097/jcma.0000000000000417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The clinical effect of atrial fibrillation (AF)-related ischemic cardiovascular events in patients undergoing peritoneal dialysis (PD) remains uncertain. This study aimed to investigate the risk of ischemic events in patients undergoing PD with new-onset AF compared with that in patients without AF and ascertain the association between the CHA2DS2-VASc score and risk of ischemic stroke. METHODS This nationwide, population-based cohort study used data from Taiwan's National Health Insurance Research Database from 1998 to 2011 for patients receiving PD with or without new-onset AF. The clinical endpoints included ischemic stroke, all-cause death, and in-hospital cardiovascular death. RESULTS Patients undergoing PD with new-onset AF (N = 505) had significantly higher risks of ischemic stroke (adjusted hazard ratio [aHR], 1.98; 95% CI, 1.40-2.80), all-cause death (aHR, 1.61; 95% CI, 1.40-1.85), and in-hospital cardiovascular death (aHR, 1.82; 95% CI, 1.50.2.21) compared with those in patients undergoing PD without AF. After considering in-hospital death as a competing risk, AF remained associated with an increased risk of ischemic stroke (hazard ratio [HR], 1.67; 95% CI, 1.17-2.37). The CHA2DS2-VASc score was associated with the risk of ischemic stroke (HR, 1.28; 95% CI, 1.12-1.46). CONCLUSION The risks of ischemic stroke, all-cause death, and in-hospital cardiovascular death were significantly higher in patients undergoing PD with AF than those in patients without AF. The CHA2DS2-VASc score remained associated with the risk of ischemic stroke in patients undergoing PD with AF.
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Affiliation(s)
- Yin-Hao Lee
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yung-Tai Chen
- Division of Nephrology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Chun-Chin Chang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Chien-Yi Hsu
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
| | - Yu-Wen Su
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Szu-Yuan Li
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chin-Chou Huang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Hsin-Bang Leu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan, ROC
- Healthcare and Services Center, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Po-Hsun Huang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Jaw-Wen Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan, ROC
- Healthcare and Services Center, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Shing-Jong Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
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17
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Ding WY, Gupta D, Wong CF, Lip GYH. Pathophysiology of atrial fibrillation and chronic kidney disease. Cardiovasc Res 2020; 117:1046-1059. [PMID: 32871005 DOI: 10.1093/cvr/cvaa258] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 07/28/2020] [Accepted: 08/25/2020] [Indexed: 01/06/2023] Open
Abstract
Atrial fibrillation (AF) and chronic kidney disease (CKD) are closely related conditions with shared risk factors. The growing prevalence of both AF and CKD indicates that more patients will suffer from concurrent conditions. There are various complex interlinking mechanisms with important implications for the management of these patients. Furthermore, there is uncertainty regarding the use of oral anticoagulation (OAC) in AF and CKD that is reflected by a lack of consensus between international guidelines. Therefore, the importance of understanding the implications of co-existing AF and CKD should not be underestimated. In this review, we discuss the pathophysiology and association between AF and CKD, including the underlying mechanisms, risk of thrombo-embolic and bleeding complications, influence on stroke management, and evidence surrounding the use of OAC for stroke prevention.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Christopher F Wong
- Department of Renal Medicine, Liverpool University Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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18
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Goel N, Jain D, Haddad DB, Shanbhogue D. Anticoagulation in Patients with End-Stage Renal Disease and Atrial Fibrillation: Confusion, Concerns and Consequences. J Stroke 2020; 22:306-316. [PMID: 33053946 PMCID: PMC7568986 DOI: 10.5853/jos.2020.01886] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 07/22/2020] [Accepted: 07/27/2020] [Indexed: 12/28/2022] Open
Abstract
End-stage renal disease (ESRD) patients have a higher prevalence of diabetes mellitus, hypertension, congestive heart failure and advanced age, along with an increased incidence of non-valvular atrial fibrillation (AF), thereby increasing the risk for cerebrovascular accidents. Systemic anticoagulation is therefore recommended in patients with ESRD with AF to reduce the risk and complications from thromboembolism. Paradoxically, these patients are at an increased risk of bleeding due to great degree of platelet dysfunction and impaired interaction between platelet and endothelium. Currently, CHA2DS2-VASc and Hypertension, Abnormal liver/kidney function, Stroke, Bleeding, Labile INR, Elderly, Drugs or alcohol (HAS-BLED) are the recommended models for stroke risk stratification and bleeding risk assessment in patients with AF. There is conflicting data regarding benefits and risks of medications such as antiplatelet agents, warfarin and direct oral anticoagulants in ESRD patients with AF. Moreover, there is no randomized controlled trial data to guide the clinical decision making. Hence, a multi-disciplinary approach with annual re-evaluation of treatment goals and risk-benefit assessment has been recommended. In this article, we review the current recommendations with risks and benefits of anticoagulation in patients with ESRD with AF.
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Affiliation(s)
- Narender Goel
- New Jersey Kidney Care, Jersey, NJ, USA
- Division of Nephrology, CarePoint Health Hospitals, Jersey, NJ, USA
- Division of Nephrology, Jersey City Medical Center, Jersey, NJ, USA
| | - Deepika Jain
- New Jersey Kidney Care, Jersey, NJ, USA
- Division of Nephrology, CarePoint Health Hospitals, Jersey, NJ, USA
- Division of Nephrology, Jersey City Medical Center, Jersey, NJ, USA
| | - Danny B. Haddad
- New Jersey Kidney Care, Jersey, NJ, USA
- Division of Nephrology, CarePoint Health Hospitals, Jersey, NJ, USA
- Division of Nephrology, Jersey City Medical Center, Jersey, NJ, USA
| | - Divya Shanbhogue
- Department of Medicine, Jersey City Medical Center, Jersey, NJ, USA
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19
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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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20
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Randhawa MS, Vishwanath R, Rai MP, Wang L, Randhawa AK, Abela G, Dhar G. Association Between Use of Warfarin for Atrial Fibrillation and Outcomes Among Patients With End-Stage Renal Disease: A Systematic Review and Meta-analysis. JAMA Netw Open 2020; 3:e202175. [PMID: 32250434 PMCID: PMC7136833 DOI: 10.1001/jamanetworkopen.2020.2175] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE Several studies have examined the role of warfarin in preventing strokes in patients with atrial fibrillation and end-stage renal disease; however, the results remain inconclusive. OBJECTIVE To assess recently published studies to examine the outcomes of the use of warfarin among patients with atrial fibrillation and end-stage renal disease. DATA SOURCES A literature search was performed using the terms warfarin and atrial fibrillation and end-stage renal disease and warfarin and atrial fibrillation and dialysis in the MEDLINE, Embase, and Google Scholar databases from January 1, 2008, to February 28, 2019. STUDY SELECTION The studies included were those with patients with end-stage renal disease and atrial fibrillation who were receiving warfarin and with hazard ratios (HRs) of at least 1 primary outcome. The studies excluded were those with a lack of information on outcomes and unreliable 95% CIs of the results. DATA EXTRACTION AND SYNTHESIS The Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines were followed in selecting studies. Collected data were also scrutinized for reliable 95% CIs. Finally, studies were examined for perceived biases, their limitations, and the definitions of the outcomes. MAIN OUTCOMES AND MEASURES The HRs and 95% CIs were calculated for the incidence of ischemic stroke, hemorrhagic stroke, major bleeding, and mortality among patients receiving anticoagulants and those not receiving anticoagulants. RESULTS Study selection yielded 15 studies with a total of 47 480 patients with atrial fibrillation and end-stage renal disease. Of these patients, 10 445 (22.0%) were taking warfarin. With a mean (SD) follow-up period of 2.6 (1.4) years, warfarin use was associated with no significant change for the risk of ischemic stroke (HR, 0.96; 95% CI, 0.82-1.13), with a significantly higher risk of hemorrhagic stroke (HR, 1.49; 95% CI, 1.03-1.94), with no significant difference in the risk of major bleeding (HR, 1.20; 95% CI, 0.99-1.47), and with no change in overall mortality (HR, 0.95; 95% CI, 0.83-1.09). CONCLUSIONS AND RELEVANCE In the studies reviewed, warfarin use appears to have been associated with no change in the incidence of ischemic stroke in patients with atrial fibrillation and end-stage renal disease. However, from the studies reviewed, it does appear to be associated with a significantly higher risk of hemorrhagic stroke, with no significant difference in the risk of major bleeding, and with no change in mortality.
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Affiliation(s)
- Mandeep S. Randhawa
- Division of Cardiology, Michigan State University, Kalamazoo
- Sparrow Clinical Research Institute, Sparrow Healthcare, Lansing, Michigan
| | | | - Manoj P. Rai
- Department of Medicine, Michigan State University, East Lansing
| | - Ling Wang
- Division of Occupational and Environment Medicine, Michigan State University, East Lansing
| | | | - George Abela
- Division of Cardiology, Michigan State University, Kalamazoo
| | - Gaurav Dhar
- Division of Cardiology, Michigan State University, Kalamazoo
- Sparrow Clinical Research Institute, Sparrow Healthcare, Lansing, Michigan
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Kuno T, Takagi H, Ando T, Sugiyama T, Miyashita S, Valentin N, Shimada YJ, Kodaira M, Numasawa Y, Briasoulis A, Burger A, Bangalore S. Oral Anticoagulation for Patients With Atrial Fibrillation on Long-Term Dialysis. J Am Coll Cardiol 2020; 75:273-285. [DOI: 10.1016/j.jacc.2019.10.059] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/28/2019] [Accepted: 10/29/2019] [Indexed: 01/06/2023]
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22
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Derebail VK, Rheault MN, Kerlin BA. Role of direct oral anticoagulants in patients with kidney disease. Kidney Int 2019; 97:664-675. [PMID: 32107019 DOI: 10.1016/j.kint.2019.11.027] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 11/01/2019] [Accepted: 11/15/2019] [Indexed: 12/13/2022]
Abstract
The anticoagulation field is experiencing a renaissance that began with regulatory approval of the direct thrombin inhibitor dabigatran, a direct oral anticoagulant (DOAC), in 2010. The DOAC medication class has rapidly evolved to include the additional approval of 4 direct factor Xa inhibitors. Commensurately, DOAC use has increased and collectively account for the majority of new anticoagulant prescriptions. Despite exclusion of patients with moderate-to-severe kidney disease from most pivotal DOAC trials, DOACs are increasingly used in this setting. An advantage of DOACs is similar or improved antithrombotic efficacy with less bleeding risk when compared with traditional agents. Several post hoc analyses, retrospective studies, claims data studies, and meta-analyses suggest that these benefits extend to patients with kidney disease. However, the lack of randomized controlled trial data in specific kidney disease settings, with their unique pathophysiology, should be a call to action for the kidney community to systematically study these agents, especially because early data suggest that DOACs may pose less risk of anticoagulant-related nephropathy than do vitamin K antagonists. Most DOACs are renally cleared and are significantly protein bound in circulation; thus, the pharmacokinetics of these drugs are influenced by reduced renal function and proteinuria. DOACs are susceptible to altered metabolism by P-glycoprotein inhibitors and inducers, including drugs commonly used for the management of kidney disease comorbidities. We summarize the currently available literature on DOAC use in kidney disease and illustrate knowledge gaps that represent important opportunities for prospective investigation.
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Affiliation(s)
- Vimal K Derebail
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michelle N Rheault
- Department of Pediatrics, Division of Pediatric Nephrology, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA.
| | - Bryce A Kerlin
- Center for Clinical and Translational Research, The Research Institute at Nationwide Children's, Columbus, Ohio, USA; Division of Hematology/Oncology/Blood & Marrow Transplantation, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
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23
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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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24
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Königsbrügge O, Ay C. Atrial fibrillation in patients with end-stage renal disease on hemodialysis: Magnitude of the problem and new approach to oral anticoagulation. Res Pract Thromb Haemost 2019; 3:578-588. [PMID: 31624777 PMCID: PMC6781927 DOI: 10.1002/rth2.12250] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 07/19/2019] [Accepted: 07/22/2019] [Indexed: 01/04/2023] Open
Abstract
Atrial fibrillation (AF) is a frequent comorbid condition in patients with end-stage renal disease on hemodialysis (HD) with a prevalence of up to 27%. The incidence rate of stroke in AF patients on HD is approximately 5%. The AF-associated risk of stroke is a major clinical challenge because current evidence for anticoagulation in HD patients with AF is based on observational data. Results from these observational studies is largely contradictory because they do not show a clear benefit of vitamin K antagonists over no treatment in terms of stroke prevention, and they show an increased risk of hemorrhage associated with anticoagulation treatment in HD patients. HD patients were not included in randomized trials of the direct oral anticoagulants (DOACs), and therefore there is no evidence to support efficacy and safety of DOACs compared to vitamin K antagonists in HD patients. The pharmacological characteristics of DOACs are of particular interest in the HD setting. The factor Xa inhibitors rivaroxaban, apixaban, and edoxaban are not predominantly eliminated via the kidneys. The thrombin inhibitor dabigatran is 80% eliminated via the kidneys but is dialyzable due to its low protein binding. In this narrative review, we examine the current state of evidence regarding the prevalence of AF in patients on HD, the associated risk of stroke, and the efficacy and safety of anticoagulation for stroke prevention in the HD setting. Further, based on the pharmacokinetic properties of DOACs, we discuss their potential use in patients on HD and ongoing randomized trials.
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Affiliation(s)
- Oliver Königsbrügge
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Cihan Ay
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
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25
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Song HY, Son KB, Shin JY, Bae S. Utilization of oral anticoagulants in Korean nonvalvular atrial fibrillation patients. Int J Clin Pharm 2019; 41:1434-1441. [PMID: 31522377 DOI: 10.1007/s11096-019-00901-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 09/05/2019] [Indexed: 12/13/2022]
Abstract
Background Although the majority of clinical guidelines indicate the use of NOAC (nonvitamin K antagonist oral anticoagulant) over vitamin K antagonist in nonvalvular atrial fibrillation patients, there is no information on real-world prescription factors that lead to a specific type of oral anticoagulant selection. Objective To evaluate the prescription factors for choosing a specific oral anticoagulant for nonvalvular atrial fibrillation patients in Korea. Setting Nationwide sampled database in South Korea. Methods In this study, we defined nonvalvular atrial fibrillation patients as having one or more hospitalizations or two or more out-patient visits with a stroke risk score (CHA2DS2-VASc scores) ≥ 2 eligible for oral anticoagulant therapy from Jan 1st, 2016 to Dec 31st, 2016. Baseline characteristics were analyzed, including sex, age, comorbidities, CHA2DS2-VASc, bleeding risk score (mHAS-BLED), prescribing specialty, insurance type, medical institution type and location. Univariate and multivariate logistic regression analyses were conducted for being prescribed NOAC compared with vitamin K antagonist. Main outcome measure Adjusted odds ratio of the NOAC group and vitamin K antagonist group. Results Of 9,226 patients eligible for oral anticoagulant therapy, 4999 patients (54.2%) received oral anticoagulant therapy, and 4517 patients took NOAC or vitamin K antagonist only during the study period. Prior stroke, transient ischemic attack, thromboembolism, thyroid disease, dyslipidemia, cancer, mHAS-BLED ≥ 5, in-patient care, and specialty in internal medicine and neurology were positive predictors of NOAC use over vitamin K antagonist, whereas young age (≤64), renal dysfunction, and secondary care institution were negative predictors of NOAC use over vitamin K antagonist. Conclusions The presence of comorbidities was linked to NOAC use over vitamin K antagonist, which is different from prescription factor studies in other countries and requires further study.
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Affiliation(s)
- Hye-Yoon Song
- College of Pharmacy, Ewha Womans University, Seoul, 03760, Republic of Korea
| | - Kyung-Bok Son
- College of Pharmacy, Ewha Womans University, Seoul, 03760, Republic of Korea
| | - Ju-Young Shin
- School of Pharmacy, Sungkyunkwan University, Suwon, 16419, Republic of Korea
| | - SeungJin Bae
- College of Pharmacy, Ewha Womans University, Seoul, 03760, Republic of Korea.
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26
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Association between Beta2-Adrenergic Receptor Agonists and the Risk of Vascular Complications in Diabetic Patients: A Population-Based Cohort Study. J Clin Med 2019; 8:jcm8081145. [PMID: 31370361 PMCID: PMC6722988 DOI: 10.3390/jcm8081145] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 07/26/2019] [Accepted: 07/29/2019] [Indexed: 12/13/2022] Open
Abstract
Beta2-adrenergic receptor (β2AR) agonists can have protective effects targeting macrophage activation, but research on human subjects has not been done. This study was designed to assess the relationship between the use of β2AR agonists and diabetic vascular complications. Using data from the Korean National Health Insurance Service, adults first diagnosed with diabetes in 2004 (n = 249,222) were followed up until 31 December 2015. Propensity score matching was performed between case and control groups (n = 5179 in each), and multivariate analysis was conducted. The β2AR agonist group was divided into quartiles according to the duration of β2AR agonist use. During the follow-up, the incidence of vascular complications gradually decreased as the duration of β2AR agonist administration increased. Multivariate analysis revealed that the hazard ratio for all composite vascular complications was 0.80 (95% CI, 0.75–0.86, p < 0.001) in the longest quartile of β2AR agonist use as compared with the control group after adjusting for confounding variables. The association between the duration of β2AR agonist use and the risk of each vascular complication including cerebrovascular, peripheral vascular, peripheral neural, renal, and ophthalmic complications was consistent, and the risks were significantly lower in the longest users than the control group. Long-term use of β2AR agonists may exert a protective effect against diabetic vascular complications.
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27
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Alshogran OY. Warfarin Dosing and Outcomes in Chronic Kidney Disease: A Closer Look at Warfarin Disposition. Curr Drug Metab 2019; 20:633-645. [PMID: 31267868 DOI: 10.2174/1389200220666190701095807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 04/02/2019] [Accepted: 06/12/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Chronic Kidney Disease (CKD) is a prevalent worldwide health problem. Patients with CKD are more prone to developing cardiovascular complications such as atrial fibrillation and stroke. This warrants the use of oral anticoagulants, such as warfarin, in this population. While the efficacy and safety of warfarin in this setting remain controversial, a growing body of evidence emphasizes that warfarin use in CKD can be problematic. This review discusses 1) warfarin use, dosing and outcomes in CKD patients; and 2) possible pharmacokinetic mechanisms for altered warfarin dosing and response in CKD. METHODS Structured search and review of literature articles evaluating warfarin dosing and outcomes in CKD. Data and information about warfarin metabolism, transport, and pharmacokinetics in CKD were also analyzed and summarized. RESULTS The literature data suggest that changes in warfarin pharmacokinetics such as protein binding, nonrenal clearance, the disposition of warfarin metabolites may partially contribute to altered warfarin dosing and response in CKD. CONCLUSION Although the evidence to support warfarin use in advanced CKD is still unclear, this synthesis of previous findings may help in improving optimized warfarin therapy in CKD settings.
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Affiliation(s)
- Osama Y Alshogran
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
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28
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Hussain S, Siddiqui AN, Baxi H, Habib A, Hussain MS, Najmi AK. Warfarin use increases bleeding risk in hemodialysis patients with atrial fibrillation: A meta-analysis of cohort studies. J Gastroenterol Hepatol 2019; 34:975-984. [PMID: 30614083 DOI: 10.1111/jgh.14601] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 12/22/2018] [Accepted: 01/02/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND AIM Atrial fibrillation is one of the most common comorbid conditions in hemodialysis patients, and warfarin is widely prescribed anticoagulant to prevent thromboembolic complications in such patients. In the last decade, several epidemiological studies pointed out the risk of bleeding with the use of warfarin. So, this meta-analysis is aimed to assess the bleeding risk associated with the use of warfarin. METHODS This meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. PubMed, Embase, Scopus, and Cochrane central databases were searched from inception to June 10, 2018. The primary outcome was to quantify the bleeding risk associated with warfarin use. The secondary outcome was to assess the bleeding risk based on different subgroups. Review Manager (RevMan) version 5.3 was used for performing statistical analysis. RESULTS A total of 15 studies, constituting a pooled sample of 53 581 patients (37.14% female), were included. Of these, 17 469 were warfarin users. We found that warfarin use had a significant association with the bleeding risk. The pooled relative risk (RR) of bleeding was estimated to be 1.35 (95% CI: 1.18-1.53, P = < 0.00001), and the pooled RR of major bleeding (five studies) was estimated to be 1.32 (95% CI: 1.07-1.63, P = 0.009). Subgroup analysis revealed a significant association of warfarin use with the intracranial hemorrhage/hemorrhagic stroke (nine studies) (pooled RR: 1.43 [95% CI: 1.20-1.71, P = < 0.0001]). CONCLUSIONS The results indicate that warfarin use increases the risk of bleeding in hemodialysis patients with atrial fibrillation.
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Affiliation(s)
- Salman Hussain
- Department of Pharmaceutical Medicine (Division of Pharmacology), School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
| | - Ali Nasir Siddiqui
- Department of Pharmaceutical Medicine (Division of Pharmacology), School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
| | - Harveen Baxi
- Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
| | - Anwar Habib
- Department of Medicine, Hamdard Institute of Medical Sciences and Research, Jamia Hamdard, New Delhi, India
| | | | - Abul Kalam Najmi
- Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
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Lei H, Yu LT, Wang WN, Zhang SG. Warfarin and the Risk of Death, Stroke, and Major Bleeding in Patients With Atrial Fibrillation Receiving Hemodialysis: A Systematic Review and Meta-Analysis. Front Pharmacol 2018; 9:1218. [PMID: 30459610 PMCID: PMC6232383 DOI: 10.3389/fphar.2018.01218] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 10/05/2018] [Indexed: 01/11/2023] Open
Abstract
Background: Up to date, the efficacy and safety of warfarin treatment in atrial fibrillation patients receiving hemodialysis remain controversial. So we performed this meta-analysis to try to offer recommendations regarding warfarin management in this population. Methods: We searched Pubmed, Embase, and Cochrane library and reviewed relevant reference lists from 1980 to March 2018. Studies were included if they described the risks of mortality, stroke, and bleeding events with or without warfarin in atrial fibrillation patients receiving hemodialysis. Results: Overall, the use of warfarin was not associated with mortality (OR = 0.95, 95%CI = 0.89–1.02), stroke (OR = 1.06, 95% CI = 0.87–1.30) and ischemic stroke (OR = 0.85, 95% CI = 0.68–1.05), but its use could increase the risks of hemorrhagic stroke (OR = 1.34, 95% CI = 1.13–1.59) and major bleeding (OR = 1.24, 95% CI = 1.14, 1.35). In subgroup analyses, when analyses were mainly restricted to atrial fibrillation patients who were undergoing hemodialysis and taking other anticoagulation agents, warfarin therapy didn't reduce the risks for mortality (OR = 0.98, 95% CI = 0.68–1.42) and ischemic stroke (OR = 1.03, 95% CI = 0.89–1.19), but significantly increased the risks of stroke (OR:1.14, 95% CI = 1.01–1.29) and bleeding events such as hemorrhagic stroke (OR = 1.42, 95% CI = 1.14–1.77) and major bleeding (OR = 1.24, 95% CI = 1.14–1.35). While in patients who didn't take other anticoagulation agents or aspirin, warfarin use was not associated with all-cause mortality (OR = 0.90, 95% CI = 0.78–1.04), or any stroke (OR = 1.00, 95% CI = 0.71–1.40). Its use was associated with significantly decreased risk of ischemic stroke (OR = 0.71, 95% CI = 0.60–0.85), but not associated with hemorrhagic stroke (OR = 1.45, 95% CI = 0.83–2.55). Besides, another subgroup analysis showed that warfarin therapy didn't exert a protective role in patients with normal serum lipid levels (OR = 1.04, 95% CI = 0.85–1.26), but seemed to decrease the risk of ischemic stroke in patients with hyperlipidemia (OR = 0.38, 95% CI = 0.11–1.29). Conclusion: Our results suggested that it was necessary to prescribe warfarin for the prevention of ischemic events in hemodialysis patients with atrial fibrillation, but if these patients were already prescribed with other anticoagulants for the treatment of other co-existing diseases, then warfarin was not recommended.
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Affiliation(s)
- Hong Lei
- Department of Traditional Medicine Testing, Institute for Drug and Instrument Control of Beijing Military Area Command, Beijing, China
| | - Li-Ting Yu
- Department of Clinical Pharmacy, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei-Ning Wang
- Department of Traditional Medicine Testing, Institute for Drug and Instrument Control of Beijing Military Area Command, Beijing, China
| | - Shun-Guo Zhang
- Department of Clinical Pharmacy, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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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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31
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Daimon S. Adverse Effect of Antithrombotic Medications on Bleeding Events and Comparison of Antithrombotic Agents in Hemodialysis Patients. Ther Apher Dial 2018; 23:32-37. [PMID: 30088338 DOI: 10.1111/1744-9987.12744] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/20/2018] [Accepted: 06/22/2018] [Indexed: 11/28/2022]
Abstract
Antithrombotic medications (AM) are mandatory for many hemodialysis patients, but the bleeding risk associated with this therapy is elevated. The frequency of bleeding events requiring discontinuation of AM, cessation of heparin use, and/or hospitalization was compared between hemodialysis patients with and without AM. All the hemodialysis patients in our clinic were investigated. AM were prescribed in 130 of 222 patients. Except for patients with cilostazol, those with AM had significantly more frequent bleeding events than those without AM (P < 0.01). Bleeding event frequency per 10 000 days of aspirin, clopidogrel, cilostazol, and warfarin prescription was 7.37, 5.95, 2.41, and 9.81, respectively, when restricted to administration of a single AM, which was 4.96, 2.87, 0.7, and 16.06, respectively. In patients without AM, it was 0.91. The bleeding risk associated with AM is elevated in hemodialysis patients and differs markedly depending on the agent used, with the lowest risk associated with cilostazol.
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Affiliation(s)
- Shoichiro Daimon
- Department of Nephrology, Daimon Clinic for Internal Medicine, Nephrology and Dialysis, Nonoichi, Japan
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32
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Lee SR, Choi EK, Han KD, Jung JH, Oh S, Lip GY. Edoxaban in Asian Patients With Atrial Fibrillation. J Am Coll Cardiol 2018; 72:838-853. [DOI: 10.1016/j.jacc.2018.05.066] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 05/18/2018] [Accepted: 05/22/2018] [Indexed: 01/17/2023]
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33
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Uso de anticoagulantes orales en situaciones clínicas complejas con fibrilación auricular. Med Clin (Barc) 2018; 150 Suppl 1:8-24. [DOI: 10.1016/s0025-7753(18)30666-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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34
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Use of oral anticoagulants in patients with atrial fibrillation and renal dysfunction. Nat Rev Nephrol 2018; 14:337-351. [PMID: 29578207 DOI: 10.1038/nrneph.2018.19] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Atrial fibrillation (AF) and chronic kidney disease (CKD) are increasingly prevalent in the general population and share common risk factors such as older age, hypertension and diabetes mellitus. The presence of CKD increases the risk of incident AF, and, likewise, AF increases the risk of CKD development and/or progression. Both conditions are associated with substantial thromboembolic risk, but patients with advanced CKD also exhibit a paradoxical increase in bleeding risk. In the landmark randomized clinical trials that compared non-vitamin K antagonist oral anticoagulants (NOACs) with warfarin for thromboprophylaxis in patients with AF, the efficacy and safety of NOACs in patients with mild-to-moderate CKD were similar to those in patients without CKD. Dose adjustment of NOACs as per the prescribing label is required in this population. Owing to limited trial data, evidence-based recommendations for the management of patients with AF and severe CKD or end-stage renal disease on dialysis are lacking. Observational cohort studies have reported conflicting results, and the management of these particularly vulnerable patients remains challenging and requires careful assessment of stroke and bleeding risk and, where appropriate, use of warfarin with good-quality anticoagulation control.
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