Bleeding in advanced CKD patients on antithrombotic medication – A critical appraisal

Burlacu, Alexandru; Genovesi, Simonetta; Goldsmith, David; Rossignol, Patrick; Ortíz, Alberto; Kalra, Philip A.; Małyszko, Jolanta; Banach, Maciej; Kanbay, Mehmet; Covic, Adrian

doi:10.1016/j.phrs.2017.12.004

Cited by 19 publications

(12 citation statements)

References 65 publications

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“…Data from one study indicated that medication with NOACs in end stage renal disease (ESRD) patients would attribute to higher risk of re-hospitalization or death from composite events when compared with warfarin (32). Moreover, the HAS-BLED score which is currently recommended by European Society of Cardiology (ESC) AF Guidelines for hemorrhagic risk stratification indicated that renal dysfunction is a powerful predictor for further bleeding risk and probably could induce more unwanted events (33).…”

Section: Discussionmentioning

confidence: 99%

Impact of Renal Function on Effectiveness and Safety Associated With Low Dose Dabigatran in Non-valve Atrial Fibrillation Patients After Catheter Ablation

Zuo

et al. 2021

Front. Cardiovasc. Med.

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Aim: The purpose of this study is to compare the effectiveness and safety of 110 mg dabigatran in non-valve atrial fibrillation (NVAF) patients with different eGFRs.Methods: We conducted a single-center retrospective cohort study to investigate the effectiveness and safety of 110 mg dabigatran for NVAF patients between January 2017 and December 2018 based on the eGFR category.Results: A total of 560 NVAF patients who treated with 110 mg dabigatran were included for analysis. In 12 months, the Kaplan-Meier survival curves indicated that the lower eGFR subgroups were more likely to experience thrombosis, bleeding, and cumulative events earlier (P = 0.021 for thrombosis; P = 0.026 for bleeding; P = 0.001 for cumulative events). Gastrointestinal bleeding occurred more frequently in the moderate group than in other groups (6.94% in the moderate group vs. 1.54% in the mild group vs. 1.22% in the normal group, P = 0.028). By multivariate analysis, chronic kidney disease (P = 0.043; OR = 4.273, 95% CI 1.043–17.543) and diabetes mellitus (P = 0.023; OR = 2.194, 95% CI 1.114–4.323) were independent predictors of the composite endpoints. A positive linear relationship was observed between eGFR levels and occurrence rate of thrombosis and bleeding under anticoagulation patients with 110 mg dabigatran (R2 = 0.432 and R2 = 0.784, respectively).Conclusions: Impaired renal function was associated with decreased safety and increased thrombosis risks in NVAF patients taking low dose dabigatran.

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Section: Discussionmentioning

confidence: 99%

Impact of Renal Function on Effectiveness and Safety Associated With Low Dose Dabigatran in Non-valve Atrial Fibrillation Patients After Catheter Ablation

Zuo

et al. 2021

Front. Cardiovasc. Med.

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“…Patients with advanced CKD/ESRD are at risk of major bleeding due to a number of reasons [ 5 ], with the risk being greatly increased by OAT. Before contemplating DAPT in anticoagulation patients undergoing PCI, careful consideration must be given to the impact on their bleeding risk, which will be significantly enhanced [ 28 ].…”

Section: Discussionmentioning

confidence: 99%

“…Two recent papers explored the thin line between the risks (both ischemic and hemorrhagic) and benefits (lower mortality) in the CKD setting, analyzing the existing evidence, indicating the missing information in terms of randomized controlled trials (RCTs), and highlighting the persistent need for new robust scores or algorithms to minimize hemorrhage risk while maximizing benefits [ 4 , 5 ]. In August 2017, the European Society of Cardiology (ESC), in collaboration with the European Association of Cardio-Thoracic Surgery, released a focused update on DAPT [ 1 ], introducing new risk stratification tools and algorithms for the treatment of patients with percutaneous coronary interventions (PCI).…”

Section: Introductionmentioning

confidence: 99%

Practical issues in clinical scenarios involving CKD patients requiring antithrombotic therapy in light of the 2017 ESC guideline recommendations

Covic

Genovesi

Rossignol

et al. 2018

BMC Med

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BackgroundThe choice of the most appropriate antithrombotic regimen that balances ischemic and bleeding risks was addressed by the August 2017 European Society of Cardiologists (ESC)/European Association for Cardio-Thoracic Surgery Focused Update recommendations, which propose new evaluation scores and protocols for patients requiring a coronary stent or patients with an acute coronary syndrome, atrial fibrillation, or a high bleeding risk and indication for oral anticoagulation therapy.DiscussionNumerous questions remain regarding antithrombotic regimens and risk management algorithms for both ischemic and hemorrhagic events in patients with chronic kidney disease (CKD) in various clinical scenarios. Limitations of current studies include a general ack of advanced CKD patients in major randomized controlled trials, of evidence on algorithm implementation, and of robust assessment tools for hemorrhagic risk. Herein, we aim to analyze the ESC Update recommendations and the newly implemented risk scores (DAPT, PRECISE-DAPT, PARIS) from the point of view of CKD, providing suggestions on drug choice (which combination has the best evidence), dosage, and duration (the same or different as for non-CKD population) of antithrombotics, as well as to identify current shortcomings and to envision directions of future research.ConclusionWe provide an evidence-based perspective on the new proposed bleeding management protocol, with focus on the CKD population. Despite previous important steps on antithrombotic therapy of renal patients, there remain many unsolved questions for which our suggestions could fundament new randomized controlled trials and specific protocols.

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“…A switching between these therapeutic options might be necessary during the disease course, while it seems to be safe and easy to manage in the daily clinical practice. The high thrombotic and bleeding risk in CAT patients, as in other groups of patients at excessive risk for adverse events, suggests that an individualized approach and treatment adjustment is crucial for a safe management and increased patient compliance [ 37 , 41 , 42 ]. Bleeding risk assessment is of major importance, as the related morbidity and mortality are high, and should be assessed during patients’ surveillance [ 42 ].…”

Section: Considerations On the Current Literaturementioning

confidence: 99%

The Role of Direct Oral Anticoagulants in Cancer-Associated Thrombosis According to the Current Literature

Nana

Dakis

Peroulis³

et al. 2021

Medicina

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Venous thromboembolism (VTE) is a common complication among patients suffering from malignancies, leading to an increased mortality rate. Novel randomized trials have added valuable information regarding cancer-associated thrombosis (CAT) management using direct oral anticoagulants (DOACs). The aim of this study is to present an overview of the current literature and recommendations in CAT treatment. A few randomized control trials (RCTs) have been integrated suggesting that DOACs may be effectively applied in CAT patients compared to low molecular weight heparins (LMWHs) with a decreased mortality and VTE recurrence rate. However, the risk of bleeding is higher, especially in patients with gastrointestinal malignancies. Real-world data are in accordance with these RCT findings, while in the currently available recommendations, DOACs are suggested as a reliable alternative to LMWH during the initial, long-term, and extended phase of treatment. Data retrieved from the current literature, including RCTs and “real-world” studies, aim to clarify the role of DOACs in CAT management, by highlighting their benefits and remarking upon the potential adverse outcomes. Current recommendations suggest the use of DOACs in well-selected patients with an increasing level of evidence through years.

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Bleeding in advanced CKD patients on antithrombotic medication – A critical appraisal

Cited by 19 publications

References 65 publications

Impact of Renal Function on Effectiveness and Safety Associated With Low Dose Dabigatran in Non-valve Atrial Fibrillation Patients After Catheter Ablation

Impact of Renal Function on Effectiveness and Safety Associated With Low Dose Dabigatran in Non-valve Atrial Fibrillation Patients After Catheter Ablation

Practical issues in clinical scenarios involving CKD patients requiring antithrombotic therapy in light of the 2017 ESC guideline recommendations

The Role of Direct Oral Anticoagulants in Cancer-Associated Thrombosis According to the Current Literature

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