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Published on: February 26, 2013
The Risk of Acute Kidney Injury with Oral Anticoagulants in Elderly Adults with Atrial Fibrillation
Ziv Harel1,2, Eric McArthur2, Nivethika Jeyakumar2
1Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
Background And Objectives:
Anticoagulation with either a vitamin K antagonist or a direct oral anticoagulant may be associated with AKI. Our objective was to assess the risk of AKI among elderly individuals with atrial fibrillation newly prescribed a direct oral anticoagulant (dabigatran, rivaroxaban, or apixaban) versus warfarin.
Design, Setting, Participants, & Measurements:
Our population-based cohort study included 20,683 outpatients in Ontario, Canada, ≥66 years with atrial fibrillation who were prescribed warfarin, dabigatran, rivaroxaban, or apixaban between 2009 and 2017. Inverse probability of treatment weighting on the basis of derived propensity scores for the treatment with each direct oral anticoagulant was used to balance baseline characteristics among patients receiving each of the three direct oral anticoagulants compared with warfarin. Cox proportional hazards regression was performed in the weighted population to compare the association between the prescribed anticoagulant and the outcomes of interest. The exposure was an outpatient prescription of warfarin or one of the direct oral anticoagulants. The primary outcome was a hospital encounter with AKI, defined using Kidney Disease Improving Global Outcomes thresholds. Prespecified subgroup analyses were conducted by eGFR category and by the percentage of international normalized ratio measurements in range, a validated marker of anticoagulation control.
Results:
Each direct oral anticoagulant was associated with a significantly lower risk of AKI compared with warfarin (weighted hazard ratio, 0.65; 95% confidence interval, 0.53 to 0.80 for dabigatran; weighted hazard ratio, 0.85; 95% confidence interval, 0.73 to 0.98 for rivaroxaban; and weighted hazard ratio, 0.81; 95% confidence interval, 0.72 to 0.93 for apixaban). In the subgroup analysis, the lower risk of AKI associated with each direct oral anticoagulant was consistent across each eGFR strata. The risk of AKI was significantly lower among users of each of the direct oral anticoagulants compared with warfarin users who had a percentage of international normalized ratio measurements ≤56%.
Conclusions:
Direct oral anticoagulants were associated with a lower risk of AKI compared with warfarin.
Insights
Direct oral anticoagulants (DOACs) significantly reduced the risk of acute kidney injury (AKI) in elderly atrial fibrillation patients compared to warfarin. This finding was consistent across different kidney function levels.
Area of Science:
- Nephrology
- Cardiology
- Pharmacology
Background:
- Anticoagulation therapy, including vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs), may be linked to acute kidney injury (AKI).
- Elderly patients with atrial fibrillation (AF) are a vulnerable population often requiring anticoagulation.
Purpose of the Study:
- To compare the risk of AKI in elderly patients with AF newly prescribed DOACs (dabigatran, rivaroxaban, apixaban) versus warfarin.
- To assess the safety profile of DOACs concerning kidney function in this patient group.
Main Methods:
- A population-based cohort study in Ontario, Canada, included 20,683 outpatients aged ≥66 years with AF.
- Inverse probability of treatment weighting (IPTW) was used to balance baseline characteristics between DOAC and warfarin users.
- Cox proportional hazards regression analyzed the association between anticoagulant type and AKI, defined by KDIGO criteria.
Main Results:
- All DOACs (dabigatran, rivaroxaban, apixaban) were associated with a significantly lower risk of AKI compared to warfarin.
- Weighted hazard ratios for AKI were 0.65 (dabigatran), 0.85 (rivaroxaban), and 0.81 (apixaban) versus warfarin.
- Reduced AKI risk with DOACs was consistent across estimated glomerular filtration rate (eGFR) strata and in patients with suboptimal warfarin control (INR ≤56%).
Conclusions:
- DOACs demonstrate a lower risk of AKI compared to warfarin in elderly patients with atrial fibrillation.
- DOACs represent a potentially safer anticoagulation option for AF patients, particularly those with varying degrees of kidney function or suboptimal anticoagulation control.
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