Thomas A Mavrakanas1,2, Katherine Garlo3, David M Charytan4. 1. Renal Division, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts tmavrakanas@gmail.com. 2. Department of Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland. 3. Renal Division, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts. 4. Nephrology Division, New York University Langone Medical Center and Grossman School of Medicine, New York, New York.
Abstract
BACKGROUND AND OBJECTIVES: The relative efficacy and safety of apixaban compared with no anticoagulation have not been studied in patients on maintenance dialysis with atrial fibrillation. We aimed to determine whether apixaban is associated with better clinical outcomes compared with no anticoagulation in this population. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This retrospective cohort study used 2012-2015 US Renal Data System data. Patients on maintenance dialysis with incident, nonvalvular atrial fibrillation treated with apixaban (521 patients) were matched for relevant baseline characteristics with patients not treated with any anticoagulant agent (1561 patients) using a propensity score. The primary outcome was hospital admission for a new stroke (ischemic or hemorrhagic), transient ischemic attack, or systemic thromboembolism. The secondary outcome was fatal or intracranial bleeding. Competing risk survival models were used. RESULTS: Compared with no anticoagulation, apixaban was not associated with lower incidence of the primary outcome: hazard ratio, 1.24; 95% confidence interval, 0.69 to 2.23; P=0.47. A significantly higher incidence of fatal or intracranial bleeding was observed with apixaban compared with no treatment: hazard ratio, 2.74; 95% confidence interval, 1.37 to 5.47; P=0.004. A trend toward fewer ischemic but more hemorrhagic strokes was seen with apixaban compared with no treatment. No significant difference in the composite outcome of myocardial infarction or ischemic stroke was seen with apixaban compared with no treatment. Compared with no anticoagulation, a significantly higher rate of the primary outcome and a significantly higher incidence of fatal or intracranial bleeding and of hemorrhagic stroke were seen in the subgroup of patients treated with the standard apixaban dose (5 mg twice daily) but not in patients who received the reduced apixaban dose (2.5 mg twice daily). CONCLUSIONS: In patients with kidney failure and nonvalvular atrial fibrillation, treatment with apixaban was not associated with a lower incidence of new stroke, transient ischemic attack, or systemic thromboembolism but was associated with a higher incidence of fatal or intracranial bleeding. PODCAST: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2020_05_29_CJN11650919.mp3.
BACKGROUND AND OBJECTIVES: The relative efficacy and safety of apixaban compared with no anticoagulation have not been studied in patients on maintenance dialysis with atrial fibrillation. We aimed to determine whether apixaban is associated with better clinical outcomes compared with no anticoagulation in this population. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This retrospective cohort study used 2012-2015 US Renal Data System data. Patients on maintenance dialysis with incident, nonvalvular atrial fibrillation treated with apixaban (521 patients) were matched for relevant baseline characteristics with patients not treated with any anticoagulant agent (1561 patients) using a propensity score. The primary outcome was hospital admission for a new stroke (ischemic or hemorrhagic), transient ischemic attack, or systemic thromboembolism. The secondary outcome was fatal or intracranial bleeding. Competing risk survival models were used. RESULTS: Compared with no anticoagulation, apixaban was not associated with lower incidence of the primary outcome: hazard ratio, 1.24; 95% confidence interval, 0.69 to 2.23; P=0.47. A significantly higher incidence of fatal or intracranial bleeding was observed with apixaban compared with no treatment: hazard ratio, 2.74; 95% confidence interval, 1.37 to 5.47; P=0.004. A trend toward fewer ischemic but more hemorrhagic strokes was seen with apixaban compared with no treatment. No significant difference in the composite outcome of myocardial infarction or ischemic stroke was seen with apixaban compared with no treatment. Compared with no anticoagulation, a significantly higher rate of the primary outcome and a significantly higher incidence of fatal or intracranial bleeding and of hemorrhagic stroke were seen in the subgroup of patients treated with the standard apixaban dose (5 mg twice daily) but not in patients who received the reduced apixaban dose (2.5 mg twice daily). CONCLUSIONS: In patients with kidney failure and nonvalvular atrial fibrillation, treatment with apixaban was not associated with a lower incidence of new stroke, transient ischemic attack, or systemic thromboembolism but was associated with a higher incidence of fatal or intracranial bleeding. PODCAST: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2020_05_29_CJN11650919.mp3.
Authors: S T Normand; M B Landrum; E Guadagnoli; J Z Ayanian; T J Ryan; P D Cleary; B J McNeil Journal: J Clin Epidemiol Date: 2001-04 Impact factor: 6.437
Authors: Konstantinos C Siontis; Xiaosong Zhang; Ashley Eckard; Nicole Bhave; Douglas E Schaubel; Kevin He; Anca Tilea; Austin G Stack; Rajesh Balkrishnan; Xiaoxi Yao; Peter A Noseworthy; Nilay D Shah; Rajiv Saran; Brahmajee K Nallamothu Journal: Circulation Date: 2018-10-09 Impact factor: 29.690
Authors: Jonathan L Thigpen; Chrisly Dillon; Kristen B Forster; Lori Henault; Emily K Quinn; Yorghos Tripodis; Peter B Berger; Elaine M Hylek; Nita A Limdi Journal: Circ Cardiovasc Qual Outcomes Date: 2015-01-13
Authors: Jenny I Shen; Maria E Montez-Rath; Colin R Lenihan; Mintu P Turakhia; Tara I Chang; Wolfgang C Winkelmayer Journal: Am J Kidney Dis Date: 2015-07-07 Impact factor: 8.860
Authors: Volker Wizemann; Lin Tong; Sudtida Satayathum; Alex Disney; Takashi Akiba; Rachel B Fissell; Peter G Kerr; Eric W Young; Bruce M Robinson Journal: Kidney Int Date: 2010-01-06 Impact factor: 10.612
Authors: John H Alexander; Richard C Becker; Deepak L Bhatt; Frank Cools; Filippo Crea; Mikael Dellborg; Keith A A Fox; Shaun G Goodman; Robert A Harrington; Kurt Huber; Steen Husted; Basil S Lewis; Jose Lopez-Sendon; Puneet Mohan; Gilles Montalescot; Mikhail Ruda; Witold Ruzyllo; Freek Verheugt; Lars Wallentin Journal: Circulation Date: 2009-05-26 Impact factor: 29.690
Authors: An S De Vriese; Rogier Caluwé; Hans Van Der Meersch; Koen De Boeck; Dirk De Bacquer Journal: J Am Soc Nephrol Date: 2021-03-22 Impact factor: 14.978
Authors: Anh Vu; Tao T Qu; Rachel Ryu; Shuktika Nandkeolyar; Alan Jacobson; Lisa T Hong Journal: Clin Appl Thromb Hemost Date: 2021 Jan-Dec Impact factor: 2.389