Min Jun1, Matthew T James2, Zhihai Ma3, Jianguo Zhang3, Marcello Tonelli2, Finlay A McAlister4, Braden J Manns2, Pietro Ravani2, Robert R Quinn2, Natasha Wiebe4, Vlado Perkovic5, Stephen B Wilton6, Wolfgang C Winkelmayer7, Brenda R Hemmelgarn8. 1. Cumming School of Medicine, Division of Nephrology, University of Calgary, Alberta, Canada; The George Institute for Global Health, The University of Sydney, Sydney, Australia. 2. Cumming School of Medicine, Division of Nephrology, University of Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada. 3. Cumming School of Medicine, Division of Nephrology, University of Calgary, Alberta, Canada. 4. Department of Medicine, University of Alberta, Edmonton, Alberta, Canada. 5. The George Institute for Global Health, The University of Sydney, Sydney, Australia. 6. Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada. 7. Section of Nephrology, Baylor College of Medicine, Houston, TX. 8. Cumming School of Medicine, Division of Nephrology, University of Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada. Electronic address: brenda.hemmelgarn@albertahealthservices.ca.
Abstract
BACKGROUND: The effectiveness and safety of warfarin use among patients with atrial fibrillation (AF) and reduced kidney function are uncertain. STUDY DESIGN: Community-based retrospective cohort study (May 1, 2003, to March 31, 2012) using province-wide laboratory and administrative data in Alberta, Canada. SETTING & PARTICIPANTS: 14,892 adults 66 years or older with new AF and a measurement of kidney function. Long-term dialysis patients or kidney transplant recipients were excluded. PREDICTOR: Propensity scores were used to construct a matched-pairs cohort of patients with AF who did and did not have a warfarin prescription within a 60-day period surrounding their AF diagnosis. OUTCOMES: Within 1 year of initiating warfarin therapy (or the matched date for nonusers): (1) the composite of all-cause death, ischemic stroke, or transient ischemic attack (also assessed as separate end points) and (2) first hospitalization or emergency department visit for a major bleeding episode defined as an intracranial, upper or lower gastrointestinal, or other bleeding. MEASUREMENTS: Baseline glomerular filtration rate (GFR) was estimated using the CKD-EPI creatinine equation. Patients were matched within estimated GFR (eGFR) categories: ≥90, 60 to 89, 45 to 59, 30 to 44, and <30mL/min/1.73m2. Information for baseline characteristics (sociodemographics, comorbid conditions, and prescription drug use) was obtained. RESULTS: Across eGFR categories, warfarin therapy initiation was associated with lower risk for the composite outcome compared to nonuse (adjusted HRs [95% CI] for eGFR categories ≥ 90, 60-89, 45-59, 30-44, and <30mL/min/1.73m2: 0.59 [0.35-1.01], 0.61 [0.54-0.70], 0.55 [0.47-0.65], 0.54 [0.44-0.67], and 0.64 [0.47-0.87] mL/min/1.73m2, respectively). Compared to nonuse, warfarin therapy was not associated with higher risk for major bleeding except for those with eGFRs of 60 to 89mL/min/1.73m2 (HR, 1.36; 95% CI, 1.13-1.64). LIMITATIONS: Selection bias. CONCLUSIONS: Among older adults with AF, warfarin therapy initiation was associated with a significantly lower 1-year risk for the composite outcome across all strata of kidney function. The risk for major bleeding associated with warfarin use was increased only among those with eGFRs of 60 to 89mL/min/1.73m2.
BACKGROUND: The effectiveness and safety of warfarin use among patients with atrial fibrillation (AF) and reduced kidney function are uncertain. STUDY DESIGN: Community-based retrospective cohort study (May 1, 2003, to March 31, 2012) using province-wide laboratory and administrative data in Alberta, Canada. SETTING & PARTICIPANTS: 14,892 adults 66 years or older with new AF and a measurement of kidney function. Long-term dialysis patients or kidney transplant recipients were excluded. PREDICTOR: Propensity scores were used to construct a matched-pairs cohort of patients with AF who did and did not have a warfarin prescription within a 60-day period surrounding their AF diagnosis. OUTCOMES: Within 1 year of initiating warfarin therapy (or the matched date for nonusers): (1) the composite of all-cause death, ischemic stroke, or transient ischemic attack (also assessed as separate end points) and (2) first hospitalization or emergency department visit for a major bleeding episode defined as an intracranial, upper or lower gastrointestinal, or other bleeding. MEASUREMENTS: Baseline glomerular filtration rate (GFR) was estimated using the CKD-EPI creatinine equation. Patients were matched within estimated GFR (eGFR) categories: ≥90, 60 to 89, 45 to 59, 30 to 44, and <30mL/min/1.73m2. Information for baseline characteristics (sociodemographics, comorbid conditions, and prescription drug use) was obtained. RESULTS: Across eGFR categories, warfarin therapy initiation was associated with lower risk for the composite outcome compared to nonuse (adjusted HRs [95% CI] for eGFR categories ≥ 90, 60-89, 45-59, 30-44, and <30mL/min/1.73m2: 0.59 [0.35-1.01], 0.61 [0.54-0.70], 0.55 [0.47-0.65], 0.54 [0.44-0.67], and 0.64 [0.47-0.87] mL/min/1.73m2, respectively). Compared to nonuse, warfarin therapy was not associated with higher risk for major bleeding except for those with eGFRs of 60 to 89mL/min/1.73m2 (HR, 1.36; 95% CI, 1.13-1.64). LIMITATIONS: Selection bias. CONCLUSIONS: Among older adults with AF, warfarin therapy initiation was associated with a significantly lower 1-year risk for the composite outcome across all strata of kidney function. The risk for major bleeding associated with warfarin use was increased only among those with eGFRs of 60 to 89mL/min/1.73m2.
Authors: Medha Airy; Jesse D Schold; Stacey E Jolly; Susana Arrigain; Nisha Bansal; Wolfgang C Winkelmayer; Joseph V Nally; Sankar D Navaneethan Journal: Am J Nephrol Date: 2018-07-26 Impact factor: 3.754
Authors: Ethan D Borre; Adam Goode; Giselle Raitz; Bimal Shah; Angela Lowenstern; Ranee Chatterjee; Lauren Sharan; Nancy M Allen LaPointe; Roshini Yapa; J Kelly Davis; Kathryn Lallinger; Robyn Schmidt; Andrzej Kosinski; Sana M Al-Khatib; Gillian D Sanders Journal: Thromb Haemost Date: 2018-10-30 Impact factor: 6.681