Rivaroxaban e malattia renale cronica: evidenze dal presente e prospettive future

2019 ◽  
Vol 31 (1) ◽  
pp. 30-36
Author(s):  
Luca Di Lullo ◽  
Claudio Ronco ◽  
Fulvio Floccari ◽  
Antonio De Pascalis ◽  
Vincenzo Barbera ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Severe Renal Impairment ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Factor X ◽  
Malattia Renale Cronica ◽  
Stage Renal Disease ◽  
End Stage ◽  
Esrd Patients

Cardiovascular diseases represent the main cause of comorbidly in chronic kidney disease (CKD) patients, with a 7% incidence in atrial fibrillation (AF) in end-stage renal disease (ESRD) patients. Until recently, prophylactic treatment of atrial fibrillation complications (such as thromboembolism) was mainly based on vitamin K antagonists (VKA) or heparin. In the last years, direct oral anticoagulants (DOACs) have been made available; however, their renal clearance limits their use on patients with severe renal impairment (eGFR <15 mL/min). Among DOACs, Rivaroxaban, a factor X-activated (Xa) inhibitor, shows good renal profile and it can be used in CKD patients up to stage 4 as well as in ESRD patients (at the moment only in North America and Canada). (Cardionephrology)

scholarly journals Anticoagulation in Patients with End-Stage Renal Disease and Atrial Fibrillation: Confusion, Concerns and Consequences

2020 ◽  
Vol 22 (3) ◽  
pp. 306-316
Author(s):  
Narender Goel ◽  
Deepika Jain ◽  
Danny B. Haddad ◽  
Divya Shanbhogue
Keyword(s):  
Atrial Fibrillation ◽  
Renal Disease ◽  
End Stage Renal Disease ◽  
Clinical Decision Making ◽  
Controlled Trial ◽  
Oral Anticoagulants ◽  
Increased Risk ◽  
Stage Renal Disease ◽  
End Stage ◽  
Esrd Patients

End-stage renal disease (ESRD) patients have a higher prevalence of diabetes mellitus, hypertension, congestive heart failure and advanced age, along with an increased incidence of non-valvular atrial fibrillation (AF), thereby increasing the risk for cerebrovascular accidents. Systemic anticoagulation is therefore recommended in patients with ESRD with AF to reduce the risk and complications from thromboembolism. Paradoxically, these patients are at an increased risk of bleeding due to great degree of platelet dysfunction and impaired interaction between platelet and endothelium. Currently, CHA2DS2-VASc and Hypertension, Abnormal liver/kidney function, Stroke, Bleeding, Labile INR, Elderly, Drugs or alcohol (HAS-BLED) are the recommended models for stroke risk stratification and bleeding risk assessment in patients with AF. There is conflicting data regarding benefits and risks of medications such as antiplatelet agents, warfarin and direct oral anticoagulants in ESRD patients with AF. Moreover, there is no randomized controlled trial data to guide the clinical decision making. Hence, a multi-disciplinary approach with annual re-evaluation of treatment goals and risk-benefit assessment has been recommended. In this article, we review the current recommendations with risks and benefits of anticoagulation in patients with ESRD with AF.

scholarly journals Clinical Evidence for the Choice of the Direct Oral Anticoagulant in Patients with Atrial Fibrillation According to Creatinine Clearance

2021 ◽  
Vol 14 (3) ◽  
pp. 279
Author(s):  
Riccardo Vio ◽  
Riccardo Proietti ◽  
Matteo Rigato ◽  
Lorenzo Arcangelo Calò
Keyword(s):  
Atrial Fibrillation ◽  
Creatinine Clearance ◽  
Stroke Prevention ◽  
Severe Renal Impairment ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Kidney Transplant Recipients ◽  
Risk Patients ◽  
End Stage

Atrial fibrillation (AF) often coexists with chronic kidney disease (CKD), which confer to the patient a higher risk of both thromboembolic and hemorrhagic events. Oral anticoagulation therapy, nowadays preferably with direct oral anticoagulants (DOACs), represents the cornerstone for ischemic stroke prevention in high-risk patients. However, all four available DOACs (dabigatran, apixaban, rivaroxaban and edoxaban) are eliminated by the kidneys to some extent. Reduced kidney function facilitates DOACs accumulation and, therefore, different dose reductions are required, with slight differences between American and European recommendations especially in case of severe renal impairment (creatinine clearance < 30 mL/min). Overall, the use of DOACs in patients with non-end stage CKD and AF is effective similarly to warfarin, showing a better safety profile. The management of thromboembolic risk among patients with AF on dialysis remains challenging, as warfarin effectiveness for stroke prevention in this population is questionable and retrospective data on apixaban need to be confirmed on a larger scale. In kidney transplant recipients, DOACs may provide a potentially safer option compared to warfarin, but co-administration with immunosuppressants is a matter of concern.

scholarly journals Role of Non-Vitamin K Oral Anticoagulants for Prevention of Stroke in Renal Impaired Atrial Fibrillation Patients

2019 ◽  
Vol 5 (1 (P)) ◽  
pp. 17
Author(s):  
Budi Yuli Setianto
Keyword(s):  
Atrial Fibrillation ◽  
Renal Dysfunction ◽  
Vitamin K ◽  
Stroke Prevention ◽  
Current Knowledge ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Cardiac Events ◽  
Stage Renal Disease ◽  
End Stage

Atrial fibrillation (AF) and chronic kidney disease (CKD) are highly prevalent, particularly with increasing of age and associated comorbidities, such as hypertension, diabetes, heart failure, and vascular disease. The relationship between AF and CKD seems to be bidirectional. CKD predisposes to AF while onset of AF seems to lead to progression of CKD. Stroke prevention is the cornerstone of AF management, and AF patients with CKD are at higher risk of stroke, mortality, cardiac events, and bleeding. Stroke prevention requires use of oral anticoagulants, which are either vitamin K antagonists (e.g. warfarin), or the non-vitamin K antagonist oral anticoagulants (NOAC). While NOAC have been shown to be effective in mild-to-moderate renal dysfunction, there are a paucity of data regarding NOAC in severe and end-stage renal dysfunction. The followingwill discuss the evidence for NOAC in CKD, and summarize the current knowledge regarding the efficacy and safety of NOAC to prevent AF-related stroke and systemic embolism in severe and end-stage renal disease.

scholarly journals Direct Oral Anticoagulants in End-Stage Renal Disease

2018 ◽  
Vol 44 (04) ◽  
pp. 353-363 ◽  
Author(s):  
Vicky Tagalakis ◽  
Adi Klil-Drori
Keyword(s):  
Atrial Fibrillation ◽  
Venous Thromboembolism ◽  
Renal Disease ◽  
End Stage Renal Disease ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
The United States ◽  
Current Evidence ◽  
Stage Renal Disease ◽  
End Stage

AbstractPatients with end-stage renal disease (ESRD) were excluded from pivotal clinical trials with oral anticoagulants. While such patients are at an increased risk of venous and arterial thromboembolism, their risk of bleeding is also elevated. It is thus of little surprise that stroke prevention with vitamin K antagonists (VKAs) in ESRD patients with atrial fibrillation is controversial, with observational evidence ranging from beneficial to harmful. This uncertainty extends to the less studied use of VKAs for venous thromboembolism in ESRD. The direct oral anticoagulants (DOACs) apixaban and rivaroxaban have now permissive labeling in the United States for atrial fibrillation in patients with ESRD; this expanded labeling has not yet occurred either in Europe or for venous thromboembolism. This review summarizes the current evidence for the pharmacology of DOACs in ESRD as well as their utilization and safety in patients with ESRD and atrial fibrillation.

scholarly journals Evaluation of Direct Oral Anticoagulant Prescribing in Patients With Moderate to Severe Renal Impairment

2021 ◽  
Vol 27 ◽  
pp. 107602962098790
Author(s):  
Clara Ting ◽  
Megan Rhoten ◽  
Jillian Dempsey ◽  
Hunter Nichols ◽  
John Fanikos ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Renal Impairment ◽  
Severe Renal Impairment ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Bleeding Events ◽  
Increase Risk ◽  
Severe Chronic Kidney Disease ◽  
Dosing Strategies ◽  
Require Dose

Patients with renal impairment require dose adjustments for direct oral anticoagulants (DOACs), though there is uncertainty regarding their use in severe chronic kidney disease. Inappropriately dosed DOACs may increase risk of ischemic events when under-dosed, or risk of bleeding when over-dosed. The purpose of this study was to describe DOAC selection, dosing strategies, and associated clinical outcomes in patients with moderate to severe renal impairment at our institution. This was a single-center retrospective analysis of adult outpatients with moderate to severe renal impairment (estimated creatinine clearance <50 mL/min, including need for hemodialysis) who were prescribed a DOAC by a cardiologist between June 1, 2015 and December 1, 2018. Outcomes evaluated included the percentage of patients who received appropriate and inappropriate DOAC dosing, prescriber reasons for inappropriate DOAC dosing if documented, and incidence of thrombotic and bleeding events. A total of 207 patients were included. Overall, 61 (29.5%) patients received inappropriate dosing, with 43 (70.5%) being under-dosed and 18 (29.5%) being over-dosed as compared to FDA-labeled dosing recommendations for atrial fibrillation or venous thromboembolism (VTE). By a median follow-up duration of 20 months, stroke occurred in 6 (3.3%) patients receiving DOACs for atrial fibrillation, and VTE occurred in 1 (4.3%) patient receiving a DOAC for VTE. International Society on Thrombosis and Haemostasis major or clinically relevant nonmajor bleeding occurred in 25 (12.1%) patients. Direct oral anticoagulants were frequently prescribed at off-label doses in patients with moderate to severe renal impairment, with a tendency toward under-dosing.

Direct Anticoagulants Versus Vitamin K Antagonists in Patients Aged 80 Years or Older With Atrial Fibrillation in a “Real-world” Nationwide Registry: Insights From the FANTASIIA Study

2020 ◽  
Vol 25 (4) ◽  
pp. 316-323
Author(s):  
Martín Ruiz Ortiz ◽  
Javier Muñiz ◽  
María Asunción Esteve-Pastor ◽  
Francisco Marín ◽  
Inmaculada Roldán ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Real World ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Left Ventricular ◽  
Anticoagulant Treatment ◽  
Cancer History

Objective: To describe major events at follow up in octogenarian patients with atrial fibrillation (AF) according to anticoagulant treatment: direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs). Methods: A total of 578 anticoagulated patients aged ≥80 years with AF were included in a prospective, observational, multicenter study. Basal features, embolic events (stroke and systemic embolism), severe bleedings, and all-cause mortality at follow up were investigated according to the anticoagulant treatment received. Results: Mean age was 84.0 ± 3.4 years, 56% were women. Direct oral anticoagulants were prescribed to 123 (21.3%) patients. Compared with 455 (78.7%) patients treated with VKAs, those treated with DOACs presented a lower frequency of permanent AF (52.9% vs 61.6%, P = .01), cancer history (4.9% vs 10.9%, P = .046), renal failure (21.1% vs 32.2%, P = .02), and left ventricular dysfunction (2.4% vs 8.0%, P = .03); and higher frequency of previous stroke (26.0% vs 16.6%, P = .02) and previous major bleeding (8.1% vs 3.6%, P = .03). There were no significant differences in Charlson, CHA2DS2VASc, nor HAS-BLED scores. At 3-year follow up, rates of embolic events, severe bleedings, and all-cause death (per 100 patients-year) were similar in both groups (DOACs vs VKAs): 0.34 vs 1.35 ( P = .15), 3.45 vs 4.41 ( P = .48), and 8.2 vs 11.0 ( P = .18), respectively, without significant differences after multivariate analysis (hazard ratio [HR]: 0.25, 95% confidence interval [CI]: 0.03-1.93, P = .19; HR: 0.88, 95% CI: 0.44-1.76, P = .72 and HR: 0.84, 95% CI: 0.53-1.33, P = .46, respectively). Conclusion: In this “real-world” registry, the differences in major events rates in octogenarians with AF were not statistically significant in those treated with DOACs versus VKAs.

scholarly journals Direct Oral Anticoagulants in Atrial Fibrillation: Practical Considerations and Remaining Issues

2021 ◽  
Vol 41 (01) ◽  
pp. 035-041
Author(s):  
Jan Beyer-Westendorf
Keyword(s):  
Atrial Fibrillation ◽  
Severe Renal Impairment ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Tube Feeding ◽  
High Body Mass Index ◽  
Short Review ◽  
Phase Iii ◽  
Phase Iii Trial ◽  
Nasogastric Tube Feeding

AbstractPreventing thromboembolic events, while minimizing bleeding risks, remains challenging when managing patients with atrial fibrillation. Despite large and successful trial programs, several clinical concerns remain which commonly relate to fears of over- or underexposure to drugs and unfavorable outcomes. After a short summary of the main phase III trial findings, this short review discusses the evidence and clinical relevance of common clinical concerns (correct direct oral anticoagulant [DOAC] dosing; DOAC in moderate-to-severe renal impairment; and the relevance of fasting, nasogastric tube feeding, or high body mass index) on DOAC plasma levels. Finally, the need for specific DOAC antidotes will be addressed.

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