Kathrine Parker1,2, John Hartemink3, Ananya Saha3, Roshni Mitra4, Penny Lewis5, Albert Power6, Satarupa Choudhuri7, Sandip Mitra3,8, Jecko Thachil9. 1. Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, UK. Kathrine.parker@postgrad.manchester.ac.uk. 2. Division of Pharmacy and Optometry, School of Health Sciences, The University of Manchester, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PT, UK. Kathrine.parker@postgrad.manchester.ac.uk. 3. Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, UK. 4. Northern Care Alliance NHS Foundation Trust, Mayo Building, Salford Royal, Stott Lane, Salford, M6 8HD, UK. 5. Division of Pharmacy and Optometry, School of Health Sciences, The University of Manchester, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PT, UK. 6. Department of Nephrology, North Bristol NHS Foundation Trust, Southmead Hospital, Southmead Road, Westbury-on-Trym, Bristol, BS10 5NB, UK. 7. Department of Haematology, Northern Care Alliance NHS Foundation Trust, Royal Oldham Hospital, Rochdale Rd, Oldham, OL1 2JH, UK. 8. Division of Cardiovascular Sciences, School of Medical Sciences, The University of Manchester, Manchester, M13 9NT, UK. 9. Department of Haematology, Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, UK.
Abstract
BACKGROUND: Patients with chronic kidney disease (CKD) have an increased risk of venous thromboembolism (VTE) and atrial fibrillation (AF). Anticoagulants have not been studied in randomised controlled trials with CrCl < 30 ml/min. The objective of this review was to identify the impact of different anticoagulant strategies in patients with advanced CKD including dialysis. METHODS: We conducted a systematic review of randomized controlled trials and cohort studies, searching electronic databases from 1946 to 2022. Studies that evaluated both thrombotic and bleeding outcomes with anticoagulant use in CrCl < 50 ml/min were included. RESULTS: Our initial search yielded 14,503 papers with 53 suitable for inclusion. RCTs comparing direct oral anticoagulants (DOACs) versus warfarin for patients with VTE and CrCl 30-50 ml/min found no difference in recurrent VTE events (RR 0.68(95% CI 0.42-1.11)) with reduced bleeding (RR 0.65 (95% CI 0.45-0.94)). Observational data in haemodialysis suggest lower risk of recurrent VTE and major bleeding with apixaban versus warfarin. Very few studies examining outcomes were available for therapeutic and prophylactic dose low molecular weight heparin for CrCl < 30 ml/min. Findings for patients with AF on dialysis were that warfarin or DOACs had a similar or higher risk of stroke compared to no anticoagulation. For patients with AF and CrCl < 30 ml/min not on dialysis, anticoagulation should be considered on an individual basis, with limited studies suggesting DOACs may have a preferable safety profile. CONCLUSION: Further studies are still required, some ongoing, in patients with advanced CKD (CrCl < 30 ml/min) to identify the safest and most effective treatment options for VTE and AF.
BACKGROUND: Patients with chronic kidney disease (CKD) have an increased risk of venous thromboembolism (VTE) and atrial fibrillation (AF). Anticoagulants have not been studied in randomised controlled trials with CrCl < 30 ml/min. The objective of this review was to identify the impact of different anticoagulant strategies in patients with advanced CKD including dialysis. METHODS: We conducted a systematic review of randomized controlled trials and cohort studies, searching electronic databases from 1946 to 2022. Studies that evaluated both thrombotic and bleeding outcomes with anticoagulant use in CrCl < 50 ml/min were included. RESULTS: Our initial search yielded 14,503 papers with 53 suitable for inclusion. RCTs comparing direct oral anticoagulants (DOACs) versus warfarin for patients with VTE and CrCl 30-50 ml/min found no difference in recurrent VTE events (RR 0.68(95% CI 0.42-1.11)) with reduced bleeding (RR 0.65 (95% CI 0.45-0.94)). Observational data in haemodialysis suggest lower risk of recurrent VTE and major bleeding with apixaban versus warfarin. Very few studies examining outcomes were available for therapeutic and prophylactic dose low molecular weight heparin for CrCl < 30 ml/min. Findings for patients with AF on dialysis were that warfarin or DOACs had a similar or higher risk of stroke compared to no anticoagulation. For patients with AF and CrCl < 30 ml/min not on dialysis, anticoagulation should be considered on an individual basis, with limited studies suggesting DOACs may have a preferable safety profile. CONCLUSION: Further studies are still required, some ongoing, in patients with advanced CKD (CrCl < 30 ml/min) to identify the safest and most effective treatment options for VTE and AF.
Authors: Giancarlo Agnelli; Harry R Buller; Alexander Cohen; Madelyn Curto; Alexander S Gallus; Margot Johnson; Urszula Masiukiewicz; Raphael Pak; John Thompson; Gary E Raskob; Jeffrey I Weitz Journal: N Engl J Med Date: 2013-07-01 Impact factor: 91.245
Authors: Kevin E Chan; Robert P Giugliano; Manesh R Patel; Stuart Abramson; Meg Jardine; Sophia Zhao; Vlado Perkovic; Franklin W Maddux; Jonathan P Piccini Journal: J Am Coll Cardiol Date: 2016-06-21 Impact factor: 24.094
Authors: Rupert M Bauersachs; Anthonie Wa Lensing; Martin H Prins; Dagmar Kubitza; Ákos F Pap; Hervé Decousus; Jan Beyer-Westendorf; Paolo Prandoni Journal: Thromb J Date: 2014-11-24