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Evidence summaries

Direct Oral Anticoagulants Versus Warfarin Among Atrial Fibrillation Patients with Chronic Kidney Disease

Direct oral anticoagulants appear to be as likely as warfarin to prevent all strokes and systemic embolic events without increasing major bleeding events among atrial fibrillation patients with kidney impairment. Level of evidence: "B"

The quality of evidence is downgraded by imprecise results (few outcome events and wide confidence intervals).

Summary

A Cochrane review [Abstract] 1 included 5 studies with a total of 12 545 subjects with atrial fibrillation (AF) and chronic kidney disease (CKD). The included studies compared direct oral anticoagulants (DOAC) (apixaban, dabigatran, edoxaban, and rivaroxaban) and dose-adjusted warfarin. Study duration ranged from 1.8 to 2.8 years. The large majority of participants included were CKD stage G3 (n=12 155), and a small number were stage G4 (n=390). CKD is classified into stage 1 (eGFR HASH(0x2f82cc8) 90 mL/min); stage 2 (60 to 89 mL/min); stage 3a (45 to 59 mL/min); stage 3b (30 to 44 mL/min); stage 4 (15 to 29 mL/min); and stage 5 (< 15 mL/min).

DOAC appeared to probably reduce the incidence of stroke and systemic embolism events compared to warfarin (table T1). No difference was observed in myocardial infarction and all-cause mortality. There were no statistically significant differences in major bleeding, minor bleeding, gastrointestinal bleeding, or intracranial haemorrhage.

DOAC versus warfarin among AF patients with CKD

OutcomeRelative effect (95% CI)Assumed risk - WarfarinCorresponding risk - DOAC (95% CI)Participants (studies)
*statistical heterogeneity I2 =63%; **statistical heterogeneity I2 =70%
All strokes andsystemic embolic eventsRR 0.81 (0.65 to 1.00)29 per 100023 per 1000(19 to 29)12 545 (5)
Myocardial infarctionRR 0.92 (0.45 to 1.90)11 per 100010 per 1000(5 to 21)2 740 (1)
All-cause mortalityRR 0.91 (0.78 to 1.05)78 per 100071 per 1000(61 to 82)9 595 (4)
Major bleedingRR 0.79 (0.59 to 1.04)*55 per 100043 per 1000(32 to 57)12 521 (5)
Minor bleedingRR 0.97(0.58 to 1.61)**74 per 100072 per 1000(43 to 119)3 012 (2)
Gastrointestinal bleedingRR 1.40(0.97 to 2.01)17 per 100024 per 1000(17 to 35)5 678 (2)
Intracranial haemorrhageRR 0.43 (0.27 to 0.69)14 per 10006 per 1000(4 to 9)12 521 (5)

Clinical comments

Note

The results chiefly reflect CKD stage G3. Application of the results to CKD stage G4 patients requires additional investigation, and CKD stage G5 patients could not be assessed.

Date of latest search:

References

  • Kimachi M, Furukawa TA, Kimachi K et al. Direct oral anticoagulants versus warfarin for preventing stroke and systemic embolic events among atrial fibrillation patients with chronic kidney disease. Cochrane Database Syst Rev 2017;(11):CD011373. [PubMed]

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