Abstract
Purpose
The aim of this study was to investigate whether oral anticoagulants can provide efficacy
and safety profiles better than no anticoagulant in patients with stages 4 or 5 chronic
kidney disease and atrial fibrillation.
Methods
From 2001 to 2017, a cohort of patients with stages 4 or 5 chronic kidney disease
and atrial fibrillation based on electronic medical records were selected from Chang
Gung Memorial Hospital system in Taiwan. Patients were divided into nonvitamin K antagonist
oral anticoagulants (NOACs), warfarin, and nonanticoagulated groups. They were followed
from the index date to the occurrence of the study outcomes or for 5 years, whichever
occurred first. The outcomes were admissions due to ischemic stroke or systemic embolism
or major bleedings. Survival analyses were conducted to estimate the incidence rates
of outcomes.
Results
A total of 3771 patients with atrial fibrillation and estimated glomerular filtration
rate less than 30 mL/min/1.73m2 were enrolled, of whom 2971 were in the nonanticoagulated group, 280 in the NOAC
group, and 520 in the warfarin group. About 25% of all subjects (940 patients) were
on dialysis. The mean follow-up was 3.2 years. After adjusting for sex, age, comorbidities,
and comedication, the warfarin group had a significantly higher risk of ischemic stroke
or systemic embolism (adjusted hazard ratio [aHR] 3.1, 95% confidence interval [CI]
2.1-4.6) than the nonanticoagulated group. The NOAC group had a similar risk of ischemic
stroke or systemic embolism (aHR 1.1; 95% CI 0.3-3.4) to that of the nonanticoagulated
group. Both the warfarin and the NOAC groups had a significantly higher major bleeding
risk than the noncoagulated group (aHR 2.8 [95% CI 2.0-3.8] for warfarin; aHR 3.1
[95% CI 1.9-5.2] for NOAC).
Conclusion
The use of NOACs or warfarin is not more effective than using no anticoagulants at
all in reducing the risk of ischemic stroke or systemic embolism. Both NOACs and warfarin
are associated with increased risk of major bleeding. Our results do not support the
use of anticoagulants in patients with atrial fibrillation and stages 4-5 chronic
kidney disease.
Keywords
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Article info
Publication history
Published online: July 03, 2019
Footnotes
Funding: This project was supported by Ministry of Science and Technology, Taiwan (107-2314-B-182A-159-MY2) and Chang-Gung Medical Foundation (CORPG3G0271, CLRPG3D0044).
Conflicts of Interest: None.
Authorship: All authors had access to the data and a role in writing this manuscript.
Identification
Copyright
© 2019 Elsevier Inc. All rights reserved.
