Abstract
BackgroundEssential information regarding efficacy and safety of vitamin K-antagonists (VKA) treatment for atrial fibrillation (AF) in non-dialysis dependent chronic kidney disease (CKD) is still lacking in current literature. The aim of our study was to compare the risks of stroke or transient ischemic attack (TIA) and major bleeds between patients without CKD (eGFR >60 ml/min), and those with moderate (eGFR 30–60 ml/min), or severe non-dialysis dependent CKD (eGFR <30 ml/min).MethodsWe included 300 patients without CKD, 294 with moderate, and 130 with severe non-dialysis dependent CKD, who were matched for age and sex. Uni- and multivariate Cox regression analyses were performed reporting hazard ratios (HRs) for the endpoint of stroke or TIA and the endpoint of major bleeds as crude values and adjusted for comorbidity and platelet-inhibitor use.ResultsOverall, 6.2% (45/724, 1.7/100 patient years) of patients developed stroke or TIA and 15.6% (113/724, 4.8/100 patient years) a major bleeding event. Patients with severe CKD were at high risk of stroke or TIA and major bleeds during VKA treatment compared with those without renal impairment, HR 2.75 (95%CI 1.25–6.05) and 1.66 (95%CI 0.97–2.86), or with moderate CKD, HR 3.93(1.71–9.00) and 1.86 (95%CI 1.08–3.21), respectively. These risks were similar for patients without and with moderate CKD. Importantly, both less time spent within therapeutic range and high INR-variability were associated with increased risks of stroke or TIA and major bleeds in severe CKD patients.ConclusionsVKA treatment for AF in patients with severe CKD has a poor safety and efficacy profile, likely related to suboptimal anticoagulation control. Our study findings stress the need for better tailored individualised anticoagulant treatment approaches for patients with AF and severe CKD.
Highlights
About one-third of atrial fibrillation (AF) patients suffer from chronic kidney disease (CKD) [1,2,3], a condition that by itself increases the risk of stroke, even in the absence of AF
The extent to which non-dialysis dependent CKD increases the risk of stroke and major bleeds in AF patients during vitamin K-antagonists (VKA) treatment is understudied, as the main focus in research in this area has been on patients with end-stage-renal disease requiring dialysis
The few studies that have focussed on risks of stroke and/or major bleeding in AF patients with non-dialysis dependent CKD were limited by their small sample size [10,12,13], the absence of information on estimated glomerular filtration rate (eGFR) levels [8], exclusion of patients with severe CKD [7], or a divergent patient cohort with various indications for VKA treatment [14]
Summary
About one-third of atrial fibrillation (AF) patients suffer from chronic kidney disease (CKD) [1,2,3], a condition that by itself increases the risk of stroke, even in the absence of AF. The extent to which non-dialysis dependent CKD increases the risk of stroke and major bleeds in AF patients during VKA treatment is understudied, as the main focus in research in this area has been on patients with end-stage-renal disease requiring dialysis These patients comprise less than 1% of the AF population [8,11]. The few studies that have focussed on risks of stroke and/or major bleeding in AF patients with non-dialysis dependent CKD were limited by their small sample size [10,12,13], the absence of information on eGFR levels [8], exclusion of patients with severe CKD [7], or a divergent patient cohort with various indications for VKA treatment [14]. The aim of our study was to compare the risks of stroke or transient ischemic attack (TIA) and major bleeds between patients without CKD (eGFR .60 ml/min), and those with moderate (eGFR 30–60 ml/min), or severe non-dialysis dependent CKD (eGFR ,30 ml/ min)
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