Direct oral anticoagulants versus warfarin for preventing stroke and systemic embolic events among atrial fibrillation patients with chronic kidney disease

Abstract

Our findings indicate that DOAC are as likely as warfarin to prevent all strokes and systemic embolic events without increasing risk of major bleeding events among AF patients with kidney impairment. These findings should encourage physicians to prescribe DOAC in AF patients with CKD without fear of bleeding. The major limitation is that the results of this study chiefly reflect CKD stage G3. Application of the results to CKD stage G4 patients requires additional investigation. Furthermore, we could not assess CKD stage G5 patients. Future reviews should assess participants at more advanced CKD stages. Additionally, we could not conduct detailed analyses of subgroups and sensitivity analyses due to lack of data.

The efficacy and safety of direct oral anticoagulants in patients with chronic renal insufficiency: A review of the literature

“…One Cochrane review showed a reduction in overall risk of bleeding with a relative risk of 0.79 (95% CI of 0.59-1.04) for patients taking DOACs as compared to those on warfarin. 22 Other studies, however, have shown increased bleeding for DOACs as compared to warfarin 2 and even those which support DOAC use have shown increased rates of bleeding in CKD by nearly four times what was observed in the ARISTOTLE trial. 18 The study by Shin et al showed an increased risk of bleeding with DOAC use; however, this was a retrospective study which should be taken consideration when comparing to the paper by Kimachi et al which included five randomized trials comparing DOACs to Warfarin.…”

Risks of anticoagulation in patients with chronic kidney disease and atrial fibrillation: More than just bleeding?

“…Thus, individuals with CKD prescribed vitamin K antagonists may be susceptible to repeated episodes of clinical or subclinical glomerular hemorrhage, resulting in faster decline in eGFR over time. Similar findings have been demonstrated with dabigatran, though there is some evidence that direct‐acting oral anticoagulants result in a lower risk of bleeding complications than vitamin K antagonists in CKD patients . Unfortunately, Posch and colleagues excluded individuals treated with direct‐acting oral anticoagulants, precluding them from examining whether the change in eGFR over time in this group differed as compared to those treated with vitamin K antagonists.…”

“…8 There is reasonable experimental data to support such speculation, 10 though there is some evidence that direct-acting oral anticoagulants result in a lower risk of bleeding complications than vitamin K antagonists in CKD patients. 13 Unfortunately, Posch and colleagues excluded individuals treated with direct-acting oral anticoagulants, precluding them from examining whether the change in eGFR over time in this group differed as compared to those treated with vitamin K antagonists. Finally, despite the use of inverse probability of treatment weighting to try to account for baseline differences in covariates, it is difficult to completely exclude the possibility that the results of the current study could be explained by confounding by indication-that is to say, individuals treated with vitamin K antagonists represented a sicker subset of individuals more prone to kidney function decline than those who were not prescribed vitamin K antagonists.…”

A synthetic heparin mimetic that allosterically inhibits factor XIa and reduces thrombosis in vivo without enhanced risk of bleeding

“…Yet, bleeding‐averse anticoagulation continues to be a significant challenge. While some reports suggest improvement in bleeding consequences with DOACs as compared to VKAs, others suggest no major improvement . Another challenge with DOACs is the difficulty of achieving rapid reversal in incidences of excessive bleeding.…”