Oral anticoagulants, time in therapeutic range and renal function over time in real-life patients with atrial fibrillation and chronic kidney disease

Abstract

AimsTo describe the use of warfarin and direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF) and chronic kidney disease (CKD), to evaluate changes in renal function over time and predictors of rapid decline, and to describe time in therapeutic range (TTR) and predictors of poor TTR among patients on warfarin.Methods and resultsUsing data from AuriculA, the Swedish oral anticoagulation registry, patients with AF on warfarin or DOAC were identified between 2013 and 2018 (N=6567). Estimated glomerular filtration rate (eGFR) was calculated and categorised into normal (≥90 mL/min/1.73 m2), mild CKD (60–89 mL/min/1.73 m2), moderate CKD (30–59 mL/min/1.73 m2), severe CKD (15–29 mL/min/1.73 m2) and end-stage CKD (<15 mL/min/1.73 m2)/dialysis. TTR was estimated using international normalised ratio (INR) measurements. Predictors of eGFR decline over time and of poor TTR were estimated using regression analysis. Between 2013 and 2018, use of DOAC increased from 9.2% to 89.3%, with a corresponding decline in warfarin. A similar trend was observed in patients with mild to moderate CKD, while DOAC over warfarin increased slower among patients with severe to end-stage CKD/dialysis. In patients treated with warfarin, the median TTR was 77.1%. Worse TTR was observed among patients with severe CKD (70.0%) and end-stage CKD/dialysis (67.5%). A gradual annual decline in eGFR was observed (−1.1 mL/min/1.73 m2), with a more rapid decline among patients with older age, female sex, diabetes mellitus and/or heart failure.ConclusionIn patients with AF, use of DOAC has steadily increased across different CKD stages, but not in patients with severe to end-stage CKD/dialysis despite these patients having poor INR control. Patients with AF have a gradual decline in renal function, with a more rapid decline among a subgroup of patients.

Major bleeding in patients with atrial fibrillation treated with apixaban versus warfarin in combination with amiodarone: nationwide cohort study

“…However, in the general warfarin population in Sweden, TTR is high, at around 77.1%. 23 Due to the observational design of the study no evidence of causation could be established, and the definition of major bleeding was based on ICD-10 codes not defined by the International Society of Thrombosis and Haemostasis (ISTH). Although the definition of major bleeding used in this study has been validated, no clinical event adjudication was made.…”

Medium-term and long-term renal function changes with direct oral anticoagulants in elderly patients with atrial fibrillation

“…Greater declines in eGFR were reported in elderly patients with AF ( Chen T.H., et al, 2022 ) and this reduction seemed to be influenced by the use of different OATs. Several studies suggest a more favorable effect of DOACs compared with WLDs with regard to renal function decline and adverse outcomes in patients with AF in the short term ( Yao X., et al, 2017 ; Pastori D., et al, 2020 ; Lee W.C., et al, 2021 ; Sitticharoenchai P., et al, 2021 ; Batra G., et al, 2022 ). However, the ROCKET-AF and ARISTOTLE trials, and several real-world studies, show no difference between the two OATs on renal function decline ( Bohm M., et al, 2015 ; Fordyce C.B., et al, 2016 ; Hijazi Z., et al, 2016 ; Fauchier L., et al, 2018 ; Lee W.C., et al, 2021 ; Pérez A.G., et al, 2022 ; Trevisan M., et al, 2022 ).…”

Should We Still Feel Reluctant About Prescribing Rivaroxaban for Advanced Chronic Kidney Disease?

“… 1 Nevertheless, an important proportion of AF patients, especially those with estimated glomerular filtration rate <30 ml/min/1.73 m 2 , were either excluded or underrepresented in the major randomized clinical trials of direct oral anticoagulants (DOACs), 2 , 3 , 4 , 5 and data on their use in persons with severe CKD are extracted mainly from real-world observational studies. 6 Furthermore, the current guidelines of American Heart Association/American College of Cardiology/Heart Rhythm Society for the management of persons with AF propose that treatment with reduced doses of direct thrombin or factor Xa inhibitors may be considered in persons with AF and moderate-to-severe CKD with an Class IIb of recommendation with a Level of Evidence: B-R. 7 The lack of solid data on the safety and effectiveness of DOACs in severe CKD frequently leads to the hesitation of physicians to prescribe DOAC in AF patients with severe CKD, pointing toward an individualized approach especially in elderly and frail patients. 8 …”