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Published on: June 16, 2014
Oral anticoagulation in patients with chronic kidney disease: A systematic review and meta-analysis
Konark Malhotra1, Muhammad F Ishfaq2, Nitin Goyal2
1From the Department of Neurology (K.M.), Charleston Area Medical Center, West Virginia University, Charleston; Department of Neurology (M.F.I., N.G., A.W.A., A.V.A., G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology (A.H.K.), University of Ioannina School of Medicine; Department of Cardiology (J.P.), Heart Failure Unit, Attikon University Hospital, National and Kapodistrian University of Athens; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Athens, Greece. konark.malhotra@yahoo.com.
Objective:
Data regarding the efficacy and safety of warfarin and non-vitamin K antagonist oral anticoagulant (NOAC) among patients with chronic kidney disease (CKD) remain scarce.
Methods:
Systematic review and meta-analysis of studies involving patients with CKD treated with oral anticoagulants were conducted to evaluate the following outcomes: ischemic stroke, intracerebral hemorrhage (ICH), combined ischemic and hemorrhagic stroke (strokecombined), stroke or systemic embolism, mortality, and major bleeding events. CKD was defined based on creatinine clearance (CrCl) ranging from mild (CrCl: 60-89 mL/min), moderate (CrCl: 30-59 mL/min), to severe (CrCl: 15-29 mL/min).
Results:
Fifteen studies (7 comparing NOAC vs warfarin and 8 comparing warfarin vs no anticoagulant) were identified comprising 78,053 patients. Warfarin (vs no anticoagulant) was associated with reduced risk of ischemic stroke (risk ratio [RR] = 0.68; 95% confidence interval [CI] 0.55-0.84]) and mortality (RR = 0.70; 95% CI 0.62-0.78). In comparison to warfarin, NOAC use lowered the risk of ICH (RR = 0.43; 95% CI 0.33-0.56), strokecombined (RR = 0.83; 95% CI 0.72-0.96), stroke or systemic embolism (RR = 0.73; 95% CI 0.62-0.85), and major bleeding (RR = 0.77; 95% CI 0.66-0.90). In adjusted analyses, warfarin use (vs no anticoagulant) was associated with reduced mortality (HRadj = 0.68; 95% CI 0.61-0.76), whereas NOAC (vs warfarin) use reduced the risk of ICH (HRadj = 0.39; 95% CI 0.30-0.50) and stroke or systemic embolism (HRadj = 0.75; 95% CI 0.65-0.88). Our sensitivity analyses comparing different NOACs exhibited that factor Xa inhibitors (compared to warfarin) consistently reduced strokecombined (RR = 0.84; 95% CI 0.73-0.96), mortality (RR = 0.84; 95% CI 0.70-1.00), ICH (RR = 0.45; 95% CI 0.24-0.85), and major bleeding (RR = 0.76; 95% CI 0.64-0.91).
Conclusions:
Among patients with CKD treated with oral anticoagulants, NOACs present with a more favorable safety and efficacy profile for various cardiovascular outcomes.
Insights
Non-vitamin K antagonist oral anticoagulants (NOACs) show better safety and efficacy than warfarin for patients with chronic kidney disease (CKD). This systematic review highlights NOACs as a preferred option for managing cardiovascular outcomes in CKD patients.
Area of Science:
- Nephrology
- Cardiology
- Pharmacology
Background:
- Limited data exists on the efficacy and safety of warfarin versus non-vitamin K antagonist oral anticoagulants (NOACs) in patients with chronic kidney disease (CKD).
- Understanding the comparative effectiveness of these anticoagulants is crucial for managing cardiovascular risks in CKD populations.
Purpose of the Study:
- To conduct a systematic review and meta-analysis comparing warfarin and NOACs in patients with CKD.
- To evaluate outcomes including ischemic stroke, intracerebral hemorrhage (ICH), stroke combined, stroke or systemic embolism, mortality, and major bleeding.
Main Methods:
- Systematic review and meta-analysis of 15 studies involving 78,053 patients with CKD.
- CKD classification based on creatinine clearance (CrCl): mild (60-89 mL/min), moderate (30-59 mL/min), and severe (15-29 mL/min).
- Outcomes assessed included ischemic stroke, ICH, combined stroke, stroke or systemic embolism, mortality, and major bleeding.
Main Results:
- Warfarin use was associated with reduced ischemic stroke and mortality compared to no anticoagulant.
- NOACs demonstrated lower risks of ICH, combined stroke, stroke or systemic embolism, and major bleeding compared to warfarin.
- Adjusted analyses confirmed warfarin's benefit in reducing mortality and NOACs' benefit in reducing ICH and stroke or systemic embolism.
Conclusions:
- Non-vitamin K antagonist oral anticoagulants (NOACs) offer a more favorable safety and efficacy profile for cardiovascular outcomes in patients with chronic kidney disease (CKD).
- NOACs represent a potentially superior therapeutic option compared to warfarin for anticoagulation in CKD patients.
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