Comparative Effectiveness and Safety of Oral Anticoagulants Across Kidney Function in Patients With Atrial Fibrillation

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 m 2 ) 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 m 2 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.

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Comparison of Estimated Glomerular Filtration Rate Equations for Dosing New Oral Anticoagulants in Patients With Atrial Fibrillation

Revista Española de Cardiología (English Edition) ◽

10.1016/j.rec.2014.06.026 ◽

2015 ◽

Vol 68 (6) ◽

pp. 497-504 ◽

Cited By ~ 3

Author(s):

Sergio Manzano-Fernández ◽

José M. Andreu-Cayuelas ◽

Francisco Marín ◽

Esteban Orenes-Piñero ◽

Pilar Gallego ◽

...

Keyword(s):

Atrial Fibrillation ◽

Glomerular Filtration Rate ◽

Glomerular Filtration ◽

Filtration Rate ◽

Estimated Glomerular Filtration Rate ◽

Oral Anticoagulants ◽

New Oral Anticoagulants ◽

Rate Equations

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A Risk Score to Guide Cystatin C Testing to Detect Occult-Reduced Estimated Glomerular Filtration Rate

American Journal of Nephrology ◽

10.1159/000439231 ◽

2015 ◽

Vol 42 (2) ◽

pp. 141-147 ◽

Cited By ~ 3

Author(s):

Carmen A. Peralta ◽

Paul Muntner ◽

Rebecca Scherzer ◽

Suzanne Judd ◽

Mary Cushman ◽

...

Keyword(s):

Glomerular Filtration Rate ◽

Glomerular Filtration ◽

Racial Differences ◽

Kidney Function ◽

Cystatin C ◽

Risk Score ◽

Filtration Rate ◽

Bayesian Model Averaging ◽

Estimated Glomerular Filtration Rate ◽

Risk Function

Background/Aims: Persons with occult-reduced estimated glomerular filtration rate (eGFR <60 ml/min/1.73 m2 detected by serum cystatin C but missed by creatinine) have high risk for complications. Among persons with preserved kidney function by creatinine-based eGFR (eGFRcreat >60 ml/min/1.73 m2), tools to guide cystatin C testing are needed. Methods: We developed a risk score to estimate an individual's probability of reduced eGFR by cystatin C (eGFRcys <60 ml/min/1.73 m2) in The Reasons for Geographic and Racial Differences in Stroke (REGARDS) study and externally validated in the Third National Health and Nutrition Examination Survey (NHANES III). We used logistic regression with Bayesian model averaging and variables available in practice. We assessed performance characteristics using calibration and discrimination measures. Results: Among 24,877 adults with preserved kidney function by creatinine, 13.5% had reduced eGFRcys. Older and Black participants, current smokers and those with higher body mass index, lower eGFRcreat, diabetes, hypertension and history of cardiovascular disease were more likely to have occult-reduced eGFR (p < 0.001). The final risk function had a c-statistic of 0.87 in REGARDS and 0.84 in NHANES. By risk score, 72% of occult-reduced eGFR cases were detected by screening only 22% of participants. Conclusions: A risk score using characteristics readily accessible in clinical practice can identify the majority of persons with reduced eGFRcys, which is missed by creatinine.

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Potential Effect of Substituting Estimated Glomerular Filtration Rate for Estimated Creatinine Clearance for Dosing of Direct Oral Anticoagulants

Journal of the American Geriatrics Society ◽

10.1111/jgs.14288 ◽

2016 ◽

Vol 64 (10) ◽

pp. 1996-2002 ◽

Cited By ~ 17

Author(s):

Janice B. Schwartz

Keyword(s):

Glomerular Filtration Rate ◽

Creatinine Clearance ◽

Glomerular Filtration ◽

Filtration Rate ◽

Estimated Glomerular Filtration Rate ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Potential Effect

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Abstract P526: Bariatric Surgery is Associated With Slower Decline in Kidney Function, Estimated by Multiple Filtration Markers

Circulation ◽

10.1161/circ.141.suppl_1.p526 ◽

2020 ◽

Vol 141 (Suppl_1) ◽

Author(s):

Alex R CHANG ◽

G. C Wood ◽

Adam Cook ◽

Xin Chu ◽

Morgan Grams

Keyword(s):

Bariatric Surgery ◽

Glomerular Filtration Rate ◽

Glomerular Filtration ◽

Kidney Function ◽

Cystatin C ◽

Filtration Rate ◽

Estimated Glomerular Filtration Rate ◽

Morbidly Obese ◽

Surgery Group

Background: Persons with morbid obesity are at increased risk for end-stage kidney disease, and prior studies have shown an association between bariatric surgery and improvements in creatinine-based estimated glomerular filtration rate (eGFR cr ). However, eGFR cr could be biased by loss of muscle mass after surgery, and creatinine-cystatin C estimated glomerular filtration rate (eGFR cr-cyc ) has been shown to be more accurate in this setting. Methods: We matched 144 patients who underwent bariatric surgery on pre-surgery age, sex, race, body mass index (BMI), and eGFR cr with 144 morbidly obese non-surgery patients at Geisinger with serial biobanked serum samples. We measured filtration markers (creatinine, cystatin C, beta-2 microglobulin [B2M] and beta-trace protein [BTP], and calculated eGFR cr-cyc using the CKD-EPI combined equation. Using mixed effects models with random intercepts, we compared changes in filtration markers and eGFR cr-cyc between surgery and non-surgery groups. Results: Mean (SD) values for age, BMI, and eGFR cr were 48.2 (10.4) years, 45.2 (6.3) kg/m 2 , and 91.7 (17.5) ml/min/1.73m 2 ; 87.5% were female, 0.7% were black, 50.3% had hypertension, and 41.0% had type 2 diabetes. Mean eGFR cr-cyc slope in the surgery group was -0.41 ml/min/1.73m 2 /yr (95% CI: -0.74, -0.08) over a mean follow-up of 9.2 (1.4) years, compared to -1.43 ml/min/1.73m 2 /yr in the non-surgery group over a mean follow-up of 8.2 (1.1) years. Bariatric surgery was associated with a 1.02 ml/min/1.73m 2 /yr slower decline in eGFR cr-cyc , and smaller increase in all 4 filtration markers (p< 0.02 for all comparisons). Conclusions: Bariatric surgery is associated with slower decline in kidney function, as assessed by eGFR cr-cyc , B2M and BTP.

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Relationship Between Metabolic Syndrome Severity and Kidney Function as Related to Gender: A Population-Based Longitudinal Study

Clinical Nursing Research ◽

10.1177/1054773818773385 ◽

2018 ◽

Vol 29 (6) ◽

pp. 355-362 ◽

Cited By ~ 1

Author(s):

Sheng-Pyng Chen ◽

Chi-Rong Li ◽

Huan-Cheng Chang ◽

Yu-Ling Li ◽

Hsiang-Chu Pai

Keyword(s):

Metabolic Syndrome ◽

Glomerular Filtration Rate ◽

Glomerular Filtration ◽

Kidney Function ◽

Filtration Rate ◽

Estimated Glomerular Filtration Rate ◽

Population Based ◽

Health Examination ◽

Z Score ◽

The Metabolic Syndrome

The purpose of this study was to explore the relationship between the metabolic syndrome severity Z-score and kidney function by gender. We also examined the estimated glomerular filtration rate in relation to other known risk factors. The study used was a population-based prospective longitudinal research design. A total of 4,838 participants (2,683 females and 2,155 males) included individuals aged >30 years who were undergoing a health examination from 2006 to 2014 in Pingzhen City, Taiwan. In the initial generalized estimated equation model analysis, which included the covariates of age of first visit, period between the first and current visit, and metabolic syndrome severity Z-score, the results indicated that the interaction between age and metabolic syndrome severity Z-score is significantly related to the estimated glomerular filtration rate for males ( p = .040). For females, the interaction between age and metabolic syndrome severity Z-score was not significant, but a higher metabolic syndrome severity Z-score was significantly associated with lower estimated glomerular filtration rate ( p = .001). After controlling for the confounders, unhealthy behaviors, and comorbidities, the metabolic syndrome severity Z-score was still a negative predictor of estimated glomerular filtration rate in both the male ( p = .005) and female ( p = .023) models.

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