Thromboembolic and Bleeding Risk in Atrial Fibrillation Patients with Chronic Kidney Disease: Role of Anticoagulation Therapy

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Abstract

Atrial fibrillation (AF) and chronic kidney disease (CKD) are strictly related; several independent risk factors of AF are often frequent in CKD patients. AF prevalence is very common among these patients, ranging between 15% and 20% in advanced stages of CKD. Moreover, the results of several studies showed that AF patients with end stage renal disease (ESRD) have a higher mortality rate than patients with preserved renal function due to an increased incidence of stroke and an unpredicted elevated hemorrhagic risk. Direct oral anticoagulants (DOACs) are currently contraindicated in patients with ESRD and vitamin K antagonists (VKAs), remaining the only drugs allowed, although they show numerous critical issues such as a narrow therapeutic window, increased tissue calcification and an unfavorable risk/benefit ratio with low stroke prevention effect and augmented risk of major bleeding. The purpose of this review is to shed light on the applications of DOAC therapy in CKD patients, especially in ESRD patients.

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(2020)

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Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization.

Alan S Go, Glenn Chertow, Dongjie Fan … (2004)

End-stage renal disease substantially increases the risks of death, cardiovascular disease, and use of specialized health care, but the effects of less severe kidney dysfunction on these outcomes are less well defined. We estimated the longitudinal glomerular filtration rate (GFR) among 1,120,295 adults within a large, integrated system of health care delivery in whom serum creatinine had been measured between 1996 and 2000 and who had not undergone dialysis or kidney transplantation. We examined the multivariable association between the estimated GFR and the risks of death, cardiovascular events, and hospitalization. The median follow-up was 2.84 years, the mean age was 52 years, and 55 percent of the group were women. After adjustment, the risk of death increased as the GFR decreased below 60 ml per minute per 1.73 m2 of body-surface area: the adjusted hazard ratio for death was 1.2 with an estimated GFR of 45 to 59 ml per minute per 1.73 m2 (95 percent confidence interval, 1.1 to 1.2), 1.8 with an estimated GFR of 30 to 44 ml per minute per 1.73 m2 (95 percent confidence interval, 1.7 to 1.9), 3.2 with an estimated GFR of 15 to 29 ml per minute per 1.73 m2 (95 percent confidence interval, 3.1 to 3.4), and 5.9 with an estimated GFR of less than 15 ml per minute per 1.73 m2 (95 percent confidence interval, 5.4 to 6.5). The adjusted hazard ratio for cardiovascular events also increased inversely with the estimated GFR: 1.4 (95 percent confidence interval, 1.4 to 1.5), 2.0 (95 percent confidence interval, 1.9 to 2.1), 2.8 (95 percent confidence interval, 2.6 to 2.9), and 3.4 (95 percent confidence interval, 3.1 to 3.8), respectively. The adjusted risk of hospitalization with a reduced estimated GFR followed a similar pattern. An independent, graded association was observed between a reduced estimated GFR and the risk of death, cardiovascular events, and hospitalization in a large, community-based population. These findings highlight the clinical and public health importance of chronic renal insufficiency. Copyright 2004 Massachusetts Medical Society

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Rivaroxaban versus warfarin in nonvalvular atrial fibrillation.

Manesh R Patel, Kenneth Mahaffey, Jyotsna Garg … (2012)

The use of warfarin reduces the rate of ischemic stroke in patients with atrial fibrillation but requires frequent monitoring and dose adjustment. Rivaroxaban, an oral factor Xa inhibitor, may provide more consistent and predictable anticoagulation than warfarin. In a double-blind trial, we randomly assigned 14,264 patients with nonvalvular atrial fibrillation who were at increased risk for stroke to receive either rivaroxaban (at a daily dose of 20 mg) or dose-adjusted warfarin. The per-protocol, as-treated primary analysis was designed to determine whether rivaroxaban was noninferior to warfarin for the primary end point of stroke or systemic embolism. In the primary analysis, the primary end point occurred in 188 patients in the rivaroxaban group (1.7% per year) and in 241 in the warfarin group (2.2% per year) (hazard ratio in the rivaroxaban group, 0.79; 95% confidence interval [CI], 0.66 to 0.96; P<0.001 for noninferiority). In the intention-to-treat analysis, the primary end point occurred in 269 patients in the rivaroxaban group (2.1% per year) and in 306 patients in the warfarin group (2.4% per year) (hazard ratio, 0.88; 95% CI, 0.74 to 1.03; P<0.001 for noninferiority; P=0.12 for superiority). Major and nonmajor clinically relevant bleeding occurred in 1475 patients in the rivaroxaban group (14.9% per year) and in 1449 in the warfarin group (14.5% per year) (hazard ratio, 1.03; 95% CI, 0.96 to 1.11; P=0.44), with significant reductions in intracranial hemorrhage (0.5% vs. 0.7%, P=0.02) and fatal bleeding (0.2% vs. 0.5%, P=0.003) in the rivaroxaban group. In patients with atrial fibrillation, rivaroxaban was noninferior to warfarin for the prevention of stroke or systemic embolism. There was no significant between-group difference in the risk of major bleeding, although intracranial and fatal bleeding occurred less frequently in the rivaroxaban group. (Funded by Johnson & Johnson and Bayer; ROCKET AF ClinicalTrials.gov number, NCT00403767.).

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Journal

Journal ID (nlm-ta): J Clin Med

Journal ID (iso-abbrev): J Clin Med

Journal ID (publisher-id): jcm

Title: Journal of Clinical Medicine

Publisher: MDPI

ISSN (Electronic): 2077-0383

Publication date (Electronic): 28 December 2020

Publication date Collection: January 2021

Volume: 10

Issue: 1

Electronic Location Identifier: 83

Affiliations

[1 ]Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; michelefg91@ 123456gmail.com (M.M.); marcoval.mariani@ 123456gmail.com (M.V.M.); paolo.severino@ 123456uniroma1.it (P.S.); carlolavalle@ 123456yaoo.it (C.L.)

[2 ]Department of Research, Innovation and Brand Reputation, ASST-Papa Giovanni XXIII, 24127 Bergamo, Italy; antoniobellasi@ 123456hotmail.com

[3 ]National Council of Research, Institute of Clinical Physiology, 56124 Pisa, Italy; dante.lucia11@ 123456gmail.com

[4 ]Nefrologia, Dialisi e Trapianto, Policlinico San Martino, 16132 Genova, Italy; maura.ravera@ 123456hsanmartino.it (M.R.); ernesto.paoletti@ 123456hsanmartino.it (E.P.)

[5 ]Department of Nephrology and Dialysis, Moscati Hospital, 83100 Avellino, Italy; brdiiorio@ 123456gmail.com

[6 ]Department of Nephrology and Dialysis, Parodi-Delfino Hospital, 00034 Colleferro, Italy; vincenzobarbera58@ 123456gmail.com

[7 ]Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX 78705, USA; domenicodellarocca@ 123456hotmail.it

[8 ]Department of Nephrology and Dialysis, Sant’Eugenio Hospital, 00144 Rome, Italy; palumbo.dr@ 123456gmail.com

Author notes

[* ]Correspondence: dilulloluca69@ 123456gmail.com ; Fax: +39-06-972233213

Author information

Michele Magnocavallo https://orcid.org/0000-0001-9883-0114

Antonio Bellasi https://orcid.org/0000-0001-7830-1645

Marco Valerio Mariani https://orcid.org/0000-0002-9480-1209

Maria Fusaro https://orcid.org/0000-0001-9478-4851

Domenico Giovanni Della Rocca https://orcid.org/0000-0003-3837-3462

Roberto Palumbo https://orcid.org/0000-0002-6299-8123

Paolo Severino https://orcid.org/0000-0001-6211-4482

Article

Publisher ID: jcm-10-00083

DOI: 10.3390/jcm10010083

PMC ID: 7796391

PubMed ID: 33379379

SO-VID: 10f911bc-f063-4289-af39-801c9e672cfe

License:

Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).

Thromboembolic and Bleeding Risk in Atrial Fibrillation Patients with Chronic Kidney Disease: Role of Anticoagulation Therapy

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Negative Pressure Wound Therapy

Most cited references 137

OUP accepted manuscript

Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization.

Rivaroxaban versus warfarin in nonvalvular atrial fibrillation.

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