Oral anticoagulation in patients with chronic kidney disease: A systematic review and meta-analysis.
meta_analysis · Level I
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- Record sourced from PubMed, PMID 31068485.
- Also identified by DOI 10.1212/WNL.0000000000007534.
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Abstract
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. 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 (stroke<sub>combined</sub>), 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). 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), stroke<sub>combined</sub> (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 (HR<sub>adj</sub> = 0.68; 95% CI 0.61-0.76), whereas NOAC (vs warfarin) use reduced the risk of ICH (HR<sub>adj</sub> = 0.39; 95% CI 0.30-0.50) and stroke or systemic embolism (HR<sub>adj</sub> = 0.75; 95% CI 0.65-0.88). Our sensitivity analyses comparing different NOACs exhibited that factor Xa inhibitors (compared to warfarin) consistently reduced stroke<sub>combined</sub> (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). Among patients with CKD treated with oral anticoagulants, NOACs present with a more favorable safety and efficacy profile for various cardiovascular outcomes.
Medical subject headings
- Anticoagulants
- Embolism
- Renal Insufficiency, Chronic
- Stroke