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Different renal function estimation formulas for adverse outcomes in patients with atrial fibrillation receiving
Yu-Wen Cheng1, Yi-Hsin Chan2, Yi-Wei Kao3
1Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
Insights
The Cockcroft-Gault (CG) formula is crucial for assessing kidney function in atrial fibrillation (AF) patients on direct oral anticoagulants (DOACs). It outperforms other formulas in predicting adverse events, guiding treatment decisions.
Area of Science:
- Nephrology
- Cardiology
- Pharmacology
Background:
- The Cockcroft-Gault (CG) formula is the standard for renal function assessment in atrial fibrillation (AF) patients using direct oral anticoagulants (DOACs).
- Alternative renal function estimation formulas exist but their comparative performance is less understood.
Purpose of the Study:
- To compare the agreement and predictive accuracy of various renal function formulas.
- To evaluate the performance of these formulas in predicting clinical outcomes for AF patients on DOAC therapy.
Main Methods:
- Retrospective analysis of 21,318 non-valvular AF patients on DOACs from a Taiwanese multicenter database (June 2012-December 2021).
- Renal function estimated using eight formulas: CG, CG-BSA, MDRD, CKD-EPI, JSN-CKDI, FAS, LMR, and EKFC.
- Concordance assessed via weighted Cohen's Kappa; predictive performance evaluated using Cox regression, ROC curves, and Harrell's C-index for composite outcomes (thromboembolism, mortality, major bleeding).
Main Results:
- Most patients had normal renal function (≥60 ml/min) across formulas, varying from 25.7% (JSN-CKDI) to 65.3% (CKD-EPI).
- Moderate concordance observed between CG and MDRD (K=0.512) or CKD-EPI (K=0.481).
- Adverse outcomes increased exponentially below 60 ml/min. The CG formula (AUC:0.707) showed superior predictive performance for adverse events compared to MDRD (AUC:0.641) and CKD-EPI (AUC:0.664).
Conclusions:
- The CG formula is essential for managing Asian AF patients treated with DOACs.
- It plays a vital role in both medication dosing and predicting adverse clinical events in this population.
Background:
The Cockcroft-Gault (CG) formula remains the gold standard for renal function assessment in patients with atrial fibrillation (AF) receiving direct oral anticoagulants (DOACs), although various other estimation formulas exist.
Objective:
To compare the concordance and predictive performance of different renal function formulas regarding clinical outcomes in patients with AF receiving DOAC therapy.
Methods:
We retrospectively enrolled 21,318 patients with non-valvular AF receiving DOACs between June 2012 and December 2021 from a multicenter database in Taiwan. Renal function was estimated using 8 formulas: CG, CG adjusted for body surface area, Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), Japanese Society of Nephrology-Chronic Kidney Disease Initiatives, Full Age Spectrum, Lund-Malmö Revised, and European Kidney Function Consortium. Concordance was assessed using weighted Cohen's Kappa. Cox regression, receiver operating characteristic (ROC) curves, and Harrell's C-index were used to evaluate their associations with clinical outcomes, defined as a composite of thromboembolism, all-cause mortality, and major bleeding.
Results:
Most patients were classified as having normal renal function (≥60 mL/min/1.73 m2 (or mL/min) across the 8 renal function formulas, with proportions ranging from 25.7% using the Japanese Society of Nephrology-Chronic Kidney Disease Initiatives formula to 65.3% using the CKD-EPI formula. The concordance between the CG and MDRD (K = 0.512; 95% confidence interval [CI], 0.493-0.530) or CKD-EPI (K = 0.481; 95% CI, 0.462-0.500) formula is only moderate. The risk of adverse composite outcomes increases exponentially when renal function falls below 60 mL/min/1.73 m2 (or mL/min) for the 8 formulas. Conversely, for patients with renal function values of ≥60 mL/min/1.73 m2 (or mL/min), the relationship diverged across the 8 formulas. Both the MDRD (area under the curve [AUC], 0.641; 95% CI, 0.633-0.649) and CKD-EPI (AUC, 0.664; 95% CI, 0.656-0.672) formulas, along with other renal function equations, demonstrated inferior discriminatory performance for predicting major adverse events compared with the CG formula (AUC, 0.707; 95% CI, 0.700-0.714).
Conclusion:
The CG formula plays a crucial role in managing Asian patients with AF in the DOAC era, proving essential for both guiding dosing and predicting adverse clinical events.
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