Renal Outcomes in Anticoagulated Patients With Atrial Fibrillation

Xiaoxi Yao, Navdeep Tangri, Bernard J. Gersh, Lindsey R. Sangaralingham, Nilay D Shah, Karl A Nath, Peter Noseworthy

Research output: Contribution to journalArticle

45 Citations (Scopus)

Abstract

Background Lifelong oral anticoagulation, either with warfarin or a non–vitamin K antagonist oral anticoagulant (NOAC), is indicated for stroke prevention in most patients with atrial fibrillation (AF). Emerging evidence suggests that NOACs may be associated with better renal outcomes than warfarin. Objectives This study aimed to compare 4 oral anticoagulant agents (apixaban, dabigatran, rivaroxaban, and warfarin) for their effects on 4 renal outcomes: ≥30% decline in estimated glomerular filtration rate (eGFR), doubling of the serum creatinine level, acute kidney injury (AKI), and kidney failure. Methods Using a large U.S. administrative database linked to laboratory results, the authors identified 9,769 patients with nonvalvular AF who started taking an oral anticoagulant agent between October 1, 2010 and April 30, 2016. Inverse probability of treatment weighting was used to balance more than 60 baseline characteristics among patients in the 4 drug cohorts. Cox proportional hazards regression was performed in the weighted population to compare oral anticoagulant agents. Results The cumulative risk at the end of 2 years for each outcome was 24.4%, 4.0%, 14.8%, and 1.7% for ≥30% decline in eGFR, doubling of serum creatinine, AKI, and kidney failure, respectively. When the 3 NOACs were pooled, they were associated with reduced risks of ≥30% decline in eGFR (hazard ratio [HR]: 0.77; 95% confidence interval [CI]: 0.66 to 0.89; p < 0.001), doubling of serum creatinine (HR: 0.62; 95% CI: 0.40 to 0.95; p = 0.03), and AKI (HR: 0.68; 95% CI: 0.58 to 0.81; p < 0.001) compared with warfarin. When comparing each NOAC with warfarin, dabigatran was associated with lower risks of ≥30% decline in eGFR and AKI; rivaroxaban was associated with lower risks of ≥30% decline in eGFR, doubling of serum creatinine, and AKI; however, apixaban did not have a statistically significant relationship with any of the renal outcomes. Conclusions Renal function decline is common among patients with AF treated with oral anticoagulant agents. NOACs, particularly dabigatran and rivaroxaban, may be associated with lower risks of adverse renal outcomes than warfarin.

Original languageEnglish (US)
Pages (from-to)2621-2632
Number of pages12
JournalJournal of the American College of Cardiology
Volume70
Issue number21
DOIs
StatePublished - Nov 28 2017

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Warfarin
Anticoagulants
Atrial Fibrillation
Glomerular Filtration Rate
Acute Kidney Injury
Kidney
Creatinine
Confidence Intervals
Serum
Renal Insufficiency
Stroke
Databases
Pharmaceutical Preparations
Population
N(4)-oleylcytosine arabinoside
Rivaroxaban
Dabigatran

Keywords

  • acute kidney injury
  • apixaban
  • chronic kidney disease
  • dabigatran
  • kidney failure
  • rivaroxaban

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Renal Outcomes in Anticoagulated Patients With Atrial Fibrillation. / Yao, Xiaoxi; Tangri, Navdeep; Gersh, Bernard J.; Sangaralingham, Lindsey R.; Shah, Nilay D; Nath, Karl A; Noseworthy, Peter.

In: Journal of the American College of Cardiology, Vol. 70, No. 21, 28.11.2017, p. 2621-2632.

Research output: Contribution to journalArticle

Yao, Xiaoxi ; Tangri, Navdeep ; Gersh, Bernard J. ; Sangaralingham, Lindsey R. ; Shah, Nilay D ; Nath, Karl A ; Noseworthy, Peter. / Renal Outcomes in Anticoagulated Patients With Atrial Fibrillation. In: Journal of the American College of Cardiology. 2017 ; Vol. 70, No. 21. pp. 2621-2632.
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abstract = "Background Lifelong oral anticoagulation, either with warfarin or a non–vitamin K antagonist oral anticoagulant (NOAC), is indicated for stroke prevention in most patients with atrial fibrillation (AF). Emerging evidence suggests that NOACs may be associated with better renal outcomes than warfarin. Objectives This study aimed to compare 4 oral anticoagulant agents (apixaban, dabigatran, rivaroxaban, and warfarin) for their effects on 4 renal outcomes: ≥30{\%} decline in estimated glomerular filtration rate (eGFR), doubling of the serum creatinine level, acute kidney injury (AKI), and kidney failure. Methods Using a large U.S. administrative database linked to laboratory results, the authors identified 9,769 patients with nonvalvular AF who started taking an oral anticoagulant agent between October 1, 2010 and April 30, 2016. Inverse probability of treatment weighting was used to balance more than 60 baseline characteristics among patients in the 4 drug cohorts. Cox proportional hazards regression was performed in the weighted population to compare oral anticoagulant agents. Results The cumulative risk at the end of 2 years for each outcome was 24.4{\%}, 4.0{\%}, 14.8{\%}, and 1.7{\%} for ≥30{\%} decline in eGFR, doubling of serum creatinine, AKI, and kidney failure, respectively. When the 3 NOACs were pooled, they were associated with reduced risks of ≥30{\%} decline in eGFR (hazard ratio [HR]: 0.77; 95{\%} confidence interval [CI]: 0.66 to 0.89; p < 0.001), doubling of serum creatinine (HR: 0.62; 95{\%} CI: 0.40 to 0.95; p = 0.03), and AKI (HR: 0.68; 95{\%} CI: 0.58 to 0.81; p < 0.001) compared with warfarin. When comparing each NOAC with warfarin, dabigatran was associated with lower risks of ≥30{\%} decline in eGFR and AKI; rivaroxaban was associated with lower risks of ≥30{\%} decline in eGFR, doubling of serum creatinine, and AKI; however, apixaban did not have a statistically significant relationship with any of the renal outcomes. Conclusions Renal function decline is common among patients with AF treated with oral anticoagulant agents. NOACs, particularly dabigatran and rivaroxaban, may be associated with lower risks of adverse renal outcomes than warfarin.",
keywords = "acute kidney injury, apixaban, chronic kidney disease, dabigatran, kidney failure, rivaroxaban",
author = "Xiaoxi Yao and Navdeep Tangri and Gersh, {Bernard J.} and Sangaralingham, {Lindsey R.} and Shah, {Nilay D} and Nath, {Karl A} and Peter Noseworthy",
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AU - Yao, Xiaoxi

AU - Tangri, Navdeep

AU - Gersh, Bernard J.

AU - Sangaralingham, Lindsey R.

AU - Shah, Nilay D

AU - Nath, Karl A

AU - Noseworthy, Peter

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N2 - Background Lifelong oral anticoagulation, either with warfarin or a non–vitamin K antagonist oral anticoagulant (NOAC), is indicated for stroke prevention in most patients with atrial fibrillation (AF). Emerging evidence suggests that NOACs may be associated with better renal outcomes than warfarin. Objectives This study aimed to compare 4 oral anticoagulant agents (apixaban, dabigatran, rivaroxaban, and warfarin) for their effects on 4 renal outcomes: ≥30% decline in estimated glomerular filtration rate (eGFR), doubling of the serum creatinine level, acute kidney injury (AKI), and kidney failure. Methods Using a large U.S. administrative database linked to laboratory results, the authors identified 9,769 patients with nonvalvular AF who started taking an oral anticoagulant agent between October 1, 2010 and April 30, 2016. Inverse probability of treatment weighting was used to balance more than 60 baseline characteristics among patients in the 4 drug cohorts. Cox proportional hazards regression was performed in the weighted population to compare oral anticoagulant agents. Results The cumulative risk at the end of 2 years for each outcome was 24.4%, 4.0%, 14.8%, and 1.7% for ≥30% decline in eGFR, doubling of serum creatinine, AKI, and kidney failure, respectively. When the 3 NOACs were pooled, they were associated with reduced risks of ≥30% decline in eGFR (hazard ratio [HR]: 0.77; 95% confidence interval [CI]: 0.66 to 0.89; p < 0.001), doubling of serum creatinine (HR: 0.62; 95% CI: 0.40 to 0.95; p = 0.03), and AKI (HR: 0.68; 95% CI: 0.58 to 0.81; p < 0.001) compared with warfarin. When comparing each NOAC with warfarin, dabigatran was associated with lower risks of ≥30% decline in eGFR and AKI; rivaroxaban was associated with lower risks of ≥30% decline in eGFR, doubling of serum creatinine, and AKI; however, apixaban did not have a statistically significant relationship with any of the renal outcomes. Conclusions Renal function decline is common among patients with AF treated with oral anticoagulant agents. NOACs, particularly dabigatran and rivaroxaban, may be associated with lower risks of adverse renal outcomes than warfarin.

AB - Background Lifelong oral anticoagulation, either with warfarin or a non–vitamin K antagonist oral anticoagulant (NOAC), is indicated for stroke prevention in most patients with atrial fibrillation (AF). Emerging evidence suggests that NOACs may be associated with better renal outcomes than warfarin. Objectives This study aimed to compare 4 oral anticoagulant agents (apixaban, dabigatran, rivaroxaban, and warfarin) for their effects on 4 renal outcomes: ≥30% decline in estimated glomerular filtration rate (eGFR), doubling of the serum creatinine level, acute kidney injury (AKI), and kidney failure. Methods Using a large U.S. administrative database linked to laboratory results, the authors identified 9,769 patients with nonvalvular AF who started taking an oral anticoagulant agent between October 1, 2010 and April 30, 2016. Inverse probability of treatment weighting was used to balance more than 60 baseline characteristics among patients in the 4 drug cohorts. Cox proportional hazards regression was performed in the weighted population to compare oral anticoagulant agents. Results The cumulative risk at the end of 2 years for each outcome was 24.4%, 4.0%, 14.8%, and 1.7% for ≥30% decline in eGFR, doubling of serum creatinine, AKI, and kidney failure, respectively. When the 3 NOACs were pooled, they were associated with reduced risks of ≥30% decline in eGFR (hazard ratio [HR]: 0.77; 95% confidence interval [CI]: 0.66 to 0.89; p < 0.001), doubling of serum creatinine (HR: 0.62; 95% CI: 0.40 to 0.95; p = 0.03), and AKI (HR: 0.68; 95% CI: 0.58 to 0.81; p < 0.001) compared with warfarin. When comparing each NOAC with warfarin, dabigatran was associated with lower risks of ≥30% decline in eGFR and AKI; rivaroxaban was associated with lower risks of ≥30% decline in eGFR, doubling of serum creatinine, and AKI; however, apixaban did not have a statistically significant relationship with any of the renal outcomes. Conclusions Renal function decline is common among patients with AF treated with oral anticoagulant agents. NOACs, particularly dabigatran and rivaroxaban, may be associated with lower risks of adverse renal outcomes than warfarin.

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