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Non–vitamin K oral anticoagulants may be best in early-stage CKD

In patients with early-stage chronic kidney disease, non–vitamin K oral anticoagulants have superior benefit-risk profiles than vitamin K antagonists, according to study results published in the Annals of Internal Medicine.

Non–vitamin K oral anticoagulants also reduced the risks for stroke or systemic embolism and hemorrhagic stroke in patients with atrial fibrillation and chronic kidney disease, according to study authors.

“Chronic kidney disease (CKD) is a prothrombotic state that is associated with substantially increased risks for arterial and venous thromboembolism,” Jeffery T. Ha, MBBS, of the George Institute for Global Health at University of New South Wales Medicine and St. George Hospital, Sydney, and colleagues wrote.

Ha and colleagues noted that patients with CKD and end-stage chronic kidney disease (ESKD) who have atrial fibrillation are not prescribed oral anticoagulants as often as those with normal kidney function due to the uncertainty of benefits in those with CKD, and potentially increased risks for bleeding and other adverse events.

Researchers conducted a systematic review and meta-analysis of studies identified through searches on several online databases. The study included randomized control trials that evaluated non–vitamin K oral anticoagulants (NOACs) or vitamin K antagonists (VKAs), included adults with CKD and reported efficacy and/or bleeding outcomes.

After screening, 45 trials with 34,082 participants that evaluated VKAs or NOACs were included in study. In the trials, anticoagulant use was evaluated in those with atrial brillation (11 trials), venous thromboembolism (11 trials), thromboprophylaxis (6 trials), for prevention of dialysis access thrombosis (8 trials) and CVD other than atrial brillation (9 trials).

Among those with atrial fibrillation and early-stage CKD, NOACs reduced risks for stroke or systemic embolism (RR = 0.79; 95% CI, 0.66-0.93; high certainty evidence) and hemorrhagic stroke (RR = 0.48; 95% CI, 0.3-0.76; moderate-certainty evidence) compared with VKAs.

Researchers found that compared with VKAs, the effects of NOACs on recurrent venous thromboembolism or venous thromboembolism related death were uncertain (RR = 0.72; 95% CI, 0.44-1.17; low-certainty evidence).

Across all trials, NOACs seemed to reduce the risk for major bleeding compared with VKAs (RR = 0.75; 95% CI, 0.56-1.01; low certainty evidence).

Ha and colleagues noted that the findings did not provide sufficient evidence to recommend the widespread use of VKAs or NOACs in patients with advanced CKD and dialysis-dependent ESKD.

In an editorial published with the study, Ainslie Hildebrand, MD, MSc, of the University of Alberta, Edmonton, Canada, and colleagues noted that two ongoing trials in patients with atrial fibrillation, RENAL-AF and AXADIA, will provide further evidence of anticoagulated use in patients with CKD and ESKD.

“Until the results of these trials become available, the decision to use anticoagulant therapy in patients with ESKD will continue to require an individualized approach that balances potential benets and harms,” they wrote. – by Erin Michael

Disclosures: Ha and Hildebrand report no relevant financial disclosures. Please see study for all other authors’ relevant financial disclosures.