Related Experiment Video
Updated: Dec 6, 2025
The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation
Published on: February 28, 2012
Comparative Effectiveness and Safety of Oral Anticoagulants Across Kidney Function in Patients With Atrial
Xiaoxi Yao1,2,3, Jonathan W Inselman1,2, Joseph S Ross4,5
1Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (X.Y., J.W.I., C.G.N., N.D.S., P.A.N.), and Department of Internal Medicine, Mayo Clinic, Rochester, MN.
Insights
Non-vitamin K antagonist oral anticoagulants (NOACs) show similar or better safety and effectiveness compared to warfarin in atrial fibrillation patients with declining kidney function. NOAC use decreases as kidney function worsens, but benefits persist across all levels.
Area of Science:
- Cardiology
- Nephrology
- Pharmacology
Background:
- Patients with atrial fibrillation and reduced kidney function were excluded from pivotal trials of non-vitamin K antagonist oral anticoagulants (NOACs).
- This exclusion raises questions about the comparative safety and effectiveness of NOACs in this population.
- Understanding oral anticoagulant use across varying kidney function levels is crucial for patient care.
Purpose of the Study:
- To compare the safety and effectiveness of different oral anticoagulants in patients with atrial fibrillation across a spectrum of kidney function.
- To investigate the utilization patterns of NOACs relative to kidney function.
Main Methods:
- A US administrative claims database with linked laboratory data was used to identify 34,569 new users of oral anticoagulants with atrial fibrillation.
- Stabilized inverse probability of treatment weighting was employed to balance four treatment groups (apixaban, dabigatran, rivaroxaban, and warfarin) on baseline characteristics.
- Outcomes including stroke, major bleeding, and mortality were compared between treatment groups.
Main Results:
- NOAC prescriptions decreased as estimated glomerular filtration rate (eGFR) declined, with only 45.0% of patients in the lowest eGFR group (15-30 mL/min/1.73 m²) receiving a NOAC.
- Compared to warfarin, apixaban, dabigatran, and rivaroxaban were associated with lower risks of stroke, major bleeding, and/or mortality.
- No significant interaction was found between treatment and eGFR categories for any outcome, suggesting consistent effects across kidney function levels.
Conclusions:
- Non-vitamin K antagonist oral anticoagulants (NOACs) are less frequently prescribed as kidney function declines but demonstrate comparable or superior safety and effectiveness relative to warfarin across the range of kidney function.
- The findings support the use of NOACs in atrial fibrillation patients with reduced kidney function.
- No evidence of substantial residual confounding was detected.
Background:
Patients with atrial fibrillation and severely decreased kidney function were excluded from the pivotal non-vitamin K antagonist oral anticoagulants (NOAC) trials, thereby raising questions about comparative safety and effectiveness in patients with reduced kidney function. The study aimed to compare oral anticoagulants across the range of kidney function in patients with atrial fibrillation.
Methods And Results:
Using a US administrative claims database with linked laboratory data, 34 569 new users of oral anticoagulants with atrial fibrillation and estimated glomerular filtration rate ≥15 mL/(min·1.73 m2) were identified between October 1, 2010 to November 29, 2017. The proportion of patients using NOACs declined with decreasing kidney function-73.5%, 69.6%, 65.4%, 59.5%, and 45.0% of the patients were prescribed a NOAC in estimated glomerular filtration rate ≥90, 60 to 90, 45 to 60, 30 to 45, 15 to 30 mL/min per 1.73 m2 groups, respectively. Stabilized inverse probability of treatment weighting was used to balance 4 treatment groups (apixaban, dabigatran, rivaroxaban, and warfarin) on 66 baseline characteristics. In comparison to warfarin, apixaban was associated with a lower risk of stroke (hazard ratio [HR], 0.57 [0.43-0.75]; P<0.001), major bleeding (HR, 0.51 [0.44-0.61]; P<0.001), and mortality (HR, 0.68 [0.56-0.83]; P<0.001); dabigatran was associated with a similar risk of stroke but a lower risk of major bleeding (HR, 0.57 [0.43-0.75]; P<0.001) and mortality (HR, 0.68 [0.48-0.98]; P=0.04); rivaroxaban was associated with a lower risk of stroke (HR, 0.69 [0.51-0.94]; P=0.02), major bleeding (HR, 0.84 [0.72-0.99]; P=0.04), and mortality (HR, 0.73 [0.58-0.91]; P=0.006). There was no significant interaction between treatment and estimated glomerular filtration rate categories for any outcome. When comparing one NOAC to another NOAC, there was no significant difference in mortality, but some differences existed for stroke or major bleeding. No relationship between treatments and falsification end points was found, suggesting no evidence for substantial residual confounding.
Conclusions:
Relative to warfarin, NOACs are used less frequently as kidney function declines. However, NOACs appears to have similar or better comparative effectiveness and safety across the range of kidney function.
Related Concept Videos
01:18Anticoagulant Drugs: Vitamin K Antagonists and Direct Oral Anticoagulants
Warfarin, a prominent vitamin K antagonist family member, exerts its effect by inhibiting the enzyme VKORC1 (vitamin K epoxide reductase complex 1). By hindering this enzyme, warfarin...
01:30Acute Kidney Injury IV: Diagnostic Studies and Prevention
01:30Anticoagulant Drugs: Low-Molecular-Weight Heparins
01:17Factors Affecting Renal Clearance: Renal Impairment
One condition associated with renal failure is uremia. Uremia is characterized by impaired glomerular filtration and fluid accumulation in the body. This condition hinders the renal clearance of drugs, resulting in drug accumulation and potential...
01:29Venous Thrombosis III: Interprofessional Care
01:18Pharmacokinetics in Geriatric Patients: Effect of Age on Drug Excretion