Efficacy and safety of warfarin in dialysis patients with atrial fibrillation: a systematic review and meta-analysis

Nochaiwong, Surapon; Ruengorn, Chidchanok; Awiphan, Rattanaporn; Dandecha, Phongsak; Noppakun, Kajohnsak; Phrommintikul, Arintaya

doi:10.1136/openhrt-2016-000441

Cited by 44 publications

(44 citation statements)

References 70 publications

(111 reference statements)

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“…Observational data support its use in CKD IV, [27][28][29][30] but the majority of studies of warfarin in ESRD, including large retrospective studies 31,32 and multiple meta-analyses, 30,33,34 demonstrate lack of benefit and possible harm. Further study with patient-level data is needed to evaluate the use of DOACs in patients with advanced CKD.…”

Section: Introductionmentioning

confidence: 99%

Efficacy and safety of direct oral anticoagulants in patients with atrial fibrillation and chronic kidney disease

Bhatia

Bailey

Ünlü

et al. 2019

Pacing Clinical Electrophis

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Background Direct oral anticoagulants (DOACs) are effective alternatives to warfarin for stroke prevention in patients with atrial fibrillation (AF) including patients with CKD III. However, data on patient outcomes with DOACs for advanced CKD are limited, while warfarin use is controversial. Methods A retrospective study of patients with AF using DOACs and CKD stages III‐V was conducted. The primary outcomes were stroke or systemic embolism and major bleeding while on DOAC therapy among CKD IV and V patients. Rates of outcomes from the DOAC trials and from previous studies of warfarin in CKD were referenced. Results Of 316 patients reviewed, 152 were included with mean CrCl of 38.8 mL/min. Stroke and systemic embolism occurred at a rate of 1.17 per 100 person‐years, with no significant difference between CKD IV/V and CKD III (P = .567). Rates were comparable to DOAC use from the DOAC trials, and lower than rates in studies of warfarin in CKD IV/V patients. There was a nonstatistically significant trend toward increased major bleeding in CKD IV/V patients. Rates of major bleeding in CKD III to V subjects were comparable to published rates for warfarin users with similar levels of renal impairment. Conclusions In our study, DOACs appeared to be as efficacious and safe in CKD IV and V as in CKD III. In addition, DOACs appeared to be more effective than, and as safe as warfarin when compared with reference studies of patients with advanced CKD. Our findings support the use of DOACs for thromboembolism prevention in patients with advanced CKD and AF.

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Section: Introductionmentioning

confidence: 99%

Efficacy and safety of direct oral anticoagulants in patients with atrial fibrillation and chronic kidney disease

Bhatia

Bailey

Ünlü

et al. 2019

Pacing Clinical Electrophis

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“…58,59 Inhibition of FXI may also attenuate clotting on the hemodialysis circuit, thereby further lowering the risk of bleeding associated with heparin therapy. In support of this concept, a small pilot study in hemodialysis patients revealed less clotting in the air trap and on the dialysis membrane with IONIS-416858 at doses of 200 or 300 mg than with placebo even though all patients received heparin during dialysis.…”

Section: Potential Indications For Fxi-directed Therapiesmentioning

confidence: 99%

2017 Scientific Sessions Sol Sherry Distinguished Lecture in Thrombosis

Weitz

Fredenburgh

2018

ATVB

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Abstract-The goal of anticoagulant therapy is to attenuate thrombosis without compromising hemostasis. Although the direct oral anticoagulants are associated with less intracranial hemorrhage than vitamin K antagonists, bleeding remains their major side effect. Factor XI has emerged as a promising target for anticoagulants that may be safer than those currently available. The focus on factor XI stems from epidemiological evidence of its role in thrombosis, the observation of attenuated thrombosis in factor XI-deficient mice, identification of novel activators, and the fact that factor XI deficiency is associated with only a mild bleeding diathesis. Proof-of-concept comes from the demonstration that compared with enoxaparin, factor XI knockdown reduces venous thromboembolism without increasing bleeding after elective knee arthroplasty. This article rationalizes the selection of factor XI as a target for new anticoagulants, reviews the agents under development, and outlines a potential path forward for their development. Visual Overview-An online visual overview is available for this article. (Arterioscler Thromb Vasc Biol. 2018;38: 304-310.

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“…Of the 20 studies reviewed, 14 demonstrated lack of benefit or even harm. The strongest evidence comes from large retrospective studies and multiple meta‐analyses …”

Section: Management By Ckd Stagementioning

confidence: 99%

“…Three large meta‐analyses, each including 13 to 20 studies and 37 000 to over 50 000 patients, failed to show benefit to the use of warfarin among ESRD or dialysis patients in either thromboembolism prevention or mortality reduction . They did, however, demonstrate increased risk of either all‐cause bleeding by 21% or major bleeding by 30% to 35% .…”

Section: Management By Ckd Stagementioning

confidence: 99%

Atrial fibrillation and chronic kidney disease: A review of options for therapeutic anticoagulation to reduce thromboembolism risk

Bhatia

Hsu

Kim

2018

Clinical Cardiology

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Atrial fibrillation and chronic kidney disease (CKD) commonly occur together, which poses a therapeutic dilemma due to increased risk of both systemic thromboembolism and bleeding. Chronic kidney disease also has implications for medication selection. The objective of this review is to evaluate the options for anticoagulation for thromboembolism prevention in patients with atrial fibrillation and chronic kidney disease. We searched PubMed for studies of patients with atrial fibrillation and CKD on warfarin or a direct oral anticoagulant (DOAC) for thromboembolism prevention through January 1 2018, in addition to evaluating major trials evaluating DOACs and warfarin use as well as society guidelines. For patients with mild to moderate chronic kidney disease, primarily observational data supports the use of warfarin, and high quality trial data and meta‐analyses support the use and possible superiority of DOACs. For patients with severe chronic kidney disease, there are limited data on warfarin which supports its use, and data for DOACs is limited primarily to pharmacologic studies which support dose reductions but lack information on patient outcomes. For patients with end‐stage renal disease, studies on warfarin are conflicting, but the majority suggest a lack of benefit and possible harm; studies in DOACs are very limited, but apixaban is the least renally cleared and may be both safe and effective. In conclusion, warfarin or DOACs may be used based on the degree of severity of chronic kidney disease, but further study in needed in patients with end‐stage renal disease.

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Efficacy and safety of warfarin in dialysis patients with atrial fibrillation: a systematic review and meta-analysis

Cited by 44 publications

References 70 publications

Efficacy and safety of direct oral anticoagulants in patients with atrial fibrillation and chronic kidney disease

Efficacy and safety of direct oral anticoagulants in patients with atrial fibrillation and chronic kidney disease

2017 Scientific Sessions Sol Sherry Distinguished Lecture in Thrombosis

Atrial fibrillation and chronic kidney disease: A review of options for therapeutic anticoagulation to reduce thromboembolism risk

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