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Hirai T, Aoyama T, Tsuji Y, Itoh T, Matsumoto Y, Iwamoto T. Kinetic-pharmacodynamic model of warfarin for prothrombin time-international normalized ratio in Japanese patients. Br J Clin Pharmacol 2024; 90:828-836. [PMID: 37953511 DOI: 10.1111/bcp.15967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 09/10/2023] [Accepted: 11/05/2023] [Indexed: 11/14/2023] Open
Abstract
AIMS Genotype-guided dosing algorithms can explain about half of the interindividual variability in prothrombin time-international normalized ratio (PT-INR) under warfarin treatment. This study aimed to refine a published kinetic-pharmacodynamic model and guide warfarin dosage for an optimal PT-INR based on renal function. METHODS Using a retrospective cohort of adult patients (>20 years) who were administered warfarin and underwent PT-INR measurements, we refined the kinetic-pharmacodynamic model with age and the genotypes of cytochrome P450 2C9 and vitamin K epoxide reductase complex subunit 1 using the PRIOR subroutine in the nonlinear-mixed-effect modelling programme. We searched the significant covariates for parameters, such as the dose rate for 50% inhibition of coagulation (EDR50 ), using a stepwise forward and backward method. Monte Carlo simulation determined a required daily dose of warfarin with a target range of PT-INR (2.0-3.0 or 1.6-2.6) based on the significant covariates. RESULTS A total of 350 patients with 2762 PT-INR measurements were enrolled (estimated glomerular filtration rate [eGFR]: 47.5 [range: 2.6-199.0] mL/min/1.73 m2 ). The final kinetic-pharmacodynamic model showed that the EDR50 changed power functionally with body surface area, serum albumin level and eGFR. Monte Carlo simulation revealed that a lower daily dose of warfarin was required to attain the target PT-INR range as eGFR decreased. CONCLUSIONS Model-informed precision dosing of warfarin is a valuable approach for estimating its dosage in patients with renal impairment.
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Affiliation(s)
- Toshinori Hirai
- Department of Pharmacy, Mie University Hospital, Faculty of Medicine, Mie University, Tsu, Mie, Japan
| | - Takahiko Aoyama
- Laboratory of Clinical Pharmacometrics, School of Pharmacy, Nihon University, Funabashi, Chiba, Japan
| | - Yasuhiro Tsuji
- Laboratory of Clinical Pharmacometrics, School of Pharmacy, Nihon University, Funabashi, Chiba, Japan
| | - Toshimasa Itoh
- Department of Pharmacy, Tokyo Women's Medical University, Medical Center East, Tokyo, Japan
| | - Yoshiaki Matsumoto
- Laboratory of Clinical Pharmacometrics, School of Pharmacy, Nihon University, Funabashi, Chiba, Japan
| | - Takuya Iwamoto
- Department of Pharmacy, Mie University Hospital, Faculty of Medicine, Mie University, Tsu, Mie, Japan
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Sueta D, Yamashita Y, Morimoto T, Muraoka N, Umetsu M, Nishimoto Y, Takada T, Ogihara Y, Nishikawa T, Ikeda N, Otsui K, Tsubata Y, Shoji M, Shikama A, Hosoi Y, Tanabe Y, Chatani R, Tsukahara K, Nakanishi N, Kim K, Ikeda S, Mo M, Kimura T, Tsujita K. The impact of renal function on clinical outcomes of patients with cancer-associated isolated distal deep vein thrombosis: Insights from the ONCO DVT study. Thromb Res 2024; 235:107-115. [PMID: 38335565 DOI: 10.1016/j.thromres.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/15/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND The multicenter, open-label, randomized clinical trial ONCO DVT compared 3-month and 12-month edoxaban treatment regimens for isolated distal deep vein thrombosis (DVT) and suggested potential benefits of prolonged edoxaban treatment in terms of thrombotic risk. However, the risk-benefit balance of prolonged edoxaban treatment in patients with renal function remains unclear. OBJECTIVES To compare the safety and efficacy of 3-month and 12-month edoxaban treatment regimens in patients with cancer-associated isolated distal DVT and different renal functions. METHODS This pre-specified subgroup analysis of the ONCO DVT study included 601 patients divided into subgroups according to renal function using a 50 mL/min creatinine clearance (Ccr) cutoff. The primary endpoint was symptomatic recurrent venous thromboembolism (VTE) and VTE-related death at 12 months and the major secondary endpoint was major bleeding at 12 months. RESULTS Among the 601 patients, 131 (21.8 %) comprised the renal dysfunction subgroup. The primary endpoint occurred in 6 (9.7 %) and 1 (1.4 %) patients in the 3-month and 12-month edoxaban groups in the renal dysfunction subgroup, respectively, and in 16 (6.6 %) and 2 (0.9 %) patients in the no renal dysfunction subgroup, respectively. The major secondary endpoint occurred in 9 (14.5 %) and 7 (10.1 %) patients in the 12-month and 3-month edoxaban groups in the renal dysfunction subgroup, and in 13 (5.3 %) and 21 (9.3 %) patients in the no renal dysfunction subgroup, respectively. CONCLUSIONS A 12-month edoxaban regiment was superior to a 3-month treatment in terms of thrombotic risk irrespective of renal function. A higher bleeding risk was not identified in patients with renal dysfunction who received prolonged edoxaban treatment.
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Affiliation(s)
- Daisuke Sueta
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo Medical University, Nishinomiya, Japan
| | - Nao Muraoka
- Division of Cardiology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Michihisa Umetsu
- Division of Vascular Surgery, Department of Surgery, Tohoku University Hospital, Sendai, Japan
| | - Yuji Nishimoto
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Takuma Takada
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yoshito Ogihara
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Tatsuya Nishikawa
- Department of Onco-Cardiology, Osaka International Cancer Institute, Osaka, Japan
| | - Nobutaka Ikeda
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Kazunori Otsui
- Division of General Internal Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yukari Tsubata
- Department of Internal Medicine, Division of Medical Oncology and Respiratory Medicine, Shimane University Faculty of Medicine, Izumo, Japan
| | - Masaaki Shoji
- Department of Cardiovascular Medicine, National Cancer Center Hospital, Tokyo, Japan
| | - Ayumi Shikama
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yutaka Hosoi
- Department of Cardiovascular surgery, Kyorin University, Tokyo, Japan
| | - Yasuhiro Tanabe
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Ryuki Chatani
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kengo Tsukahara
- Division of Cardiology, Fujisawa City Hospital, Fujisawa, Japan
| | - Naohiko Nakanishi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Satoshi Ikeda
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Makoto Mo
- Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital, Yokohama, Japan
| | - Takeshi Kimura
- Department of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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Zhao S, Chen Y, Zhu B, Wang J, Wei Z, Zou Y, Hu W, Chen G, Wang H, Xia C, Yu T, Han P, Yang L, Wang W, Zhai Z, Gao H, Li C, Lian K. Percutaneous coronary intervention improves quality of life of patients with chronic total occlusion and low estimated glomerular filtration rate. Front Cardiovasc Med 2022; 9:1019688. [PMID: 36620621 PMCID: PMC9812571 DOI: 10.3389/fcvm.2022.1019688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022] Open
Abstract
Background A low estimated glomerular filtration rate (eGFR <90 mL/min/1.73 m2) is widely recognized as a risk factor for major adverse cardiac events (MACE) after percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). However, the impact of successful CTO-PCI on quality of life (QOL) of patients with low eGFR remains unknown. Objectives The aim of this prospective study was to assess the QOL of CTO patients with low eGFR after successful PCI. Methods Consecutive patients undergoing elective CTO-PCI were prospectively enrolled and subdivided into four groups: eGFR ≥90 mL/min/1.73 m2 (n = 410), 90 > eGFR ≥ 60 mL/min/1.73 m2 (n = 482), 60 > eGFR ≥ 30 mL/min/1.73 m2 (n = 161), and eGFR <30 mL/min/1.73 m2 (n = 23). The primary outcomes included QOL, as assessed with the European Quality of Life-5 Dimensions (EQ-5D) questionnaire, and symptoms, as assessed with the Rose Dyspnea Scale (RDS) and Seattle Angina Questionnaire (SAQ), at 1 month and 1 year after successful PCI. Results With the decline of eGFR, CTO patients were more likely to present with comorbidities of hypertension, diabetes, hyperuricemia, and previous stroke, in addition to lower hemoglobin levels and left ventricular ejection fraction (p < 0.05). Low eGFR was associated with greater incidences of in-hospital pericardiocentesis, major bleeding, acute renal failure, and subcutaneous hematoma, but not in-hospital MACE (p < 0.05). Symptoms of dyspnea and angina were alleviated in all CTO patients with eGFR ≥30 mL/min/1.73 m2 at 1 month and 1 year after successful CTO-PCI, but only at 1 month for those with eGFR <30 mL/min/1.73 m2 (p < 0.01). Importantly, QOL was markedly improved at 1 month and 1 year after successful PCI (p < 0.01), notably at a similar degree between patients with low eGFR and those with normal eGFR (p > 0.05). Conclusion Successful PCI effectively improved symptoms and QOL of CTO patients with low eGFR.
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Affiliation(s)
- Shuai Zhao
- Department of Cardiology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yan Chen
- Department of Cardiology, No. 971 Hospital of the PLA Navy, Qingdao, Shandong, China
| | - Boda Zhu
- Department of Cardiology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China,Primary Flight Training Base, Air Force Aviation University, Harbin, Heilongjiang, China
| | - Jiayi Wang
- Cadet Brigade, School of Basic Medicine, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Zhihong Wei
- Department of Cardiology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yiming Zou
- Cadet Brigade, School of Basic Medicine, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Wentao Hu
- Cadet Brigade, School of Basic Medicine, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Genrui Chen
- Department of Cardiology, Hanyin County People's Hospital, Ankang, Shaanxi, China
| | - Huan Wang
- Department of Cardiology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Chenhai Xia
- Department of Cardiology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Tiantong Yu
- Department of Cardiology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Peng Han
- Department of Cardiology, 981 Hospital of Joint Logistics Support Force, Chengde, Hebei, China
| | - Li Yang
- Department of Cardiology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Wei Wang
- Department of Pharmaceutics and Pharmacy Administration, School of Pharmacy, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Zhongjie Zhai
- Department of Health Statistics, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Haokao Gao
- Department of Cardiology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China,Haokao Gao
| | - Chengxiang Li
- Department of Cardiology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China,Chengxiang Li
| | - Kun Lian
- Department of Cardiology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China,*Correspondence: Kun Lian ;
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Kodani E, Inoue H, Atarashi H, Tomita H, Okumura K, Yamashita T, Origasa H. Predictive ability of creatinine clearance versus estimated glomerular filtration rate for outcomes in patients with non-valvular atrial fibrillation: Subanalysis of the J-RHYTHM Registry. IJC HEART & VASCULATURE 2020; 29:100559. [PMID: 32566722 PMCID: PMC7298529 DOI: 10.1016/j.ijcha.2020.100559] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/01/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Renal impairment is a risk factor for various adverse events, especially for death. In general, creatinine clearance (CrCl) is used for dose-adjustments of many drugs including oral anticoagulants, and estimated glomerular filtration rate (eGFR) is adopted for the diagnosis of chronic kidney disease. Predictive ability of CrCl versus eGFR for outcomes in patients with non-valvular atrial fibrillation (NVAF) remains controversial; therefore, this was compared using data from the J-RHYTHM Registry. METHODS Out of 7406 outpatients with NVAF from 158 institutions, 6004 (age, 69.7 ± 9.9 years; men, 71.2%) having data of CrCl (mL/min, by the Cockcroft-Gault formula), eGFR (mL/min/1.73 m2, by the equations of the Japanese Society of Nephrology), and body surface area (BSA) were analyzed. C-statistics (area under the receiver-operating characteristic curve) of CrCl and eGFR for events were compared by DeLong's test. RESULTS Thromboembolism, major hemorrhage, and all-cause death occurred in 107 (1.8%), 117 (1.9%), and 154 (2.6%) patients during the 2-year follow-up period. C-statistics of CrCl for each event were 0.609 (95% confidence interval, 0.559-0.658), 0.599 (0.548-0.657), and 0.746 (0.706-0.786); and those of eGFR were 0.542 (0.487-0.597), 0.573 (0.519-0.626), and 0.677 (0.631-0.723), respectively. C-statistics of CrCl for thromboembolism and all-cause death were significantly higher than those of eGFR (P < 0.001 for both). These results were consistent when BSA-unadjusted eGFR was used instead of eGFR (P = 0.002 for thromboembolism and P < 0.001 for all-cause death). CONCLUSIONS CrCl was superior to eGFR in the prediction of adverse outcomes, i.e., thromboembolism and all-cause death in Japanese patients with NVAF.
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Affiliation(s)
- Eitaro Kodani
- Department of Internal Medicine and Cardiology, Nippon Medical School Tama-Nagayama Hospital, Tokyo, Japan
| | | | | | - Hirofumi Tomita
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Ken Okumura
- Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | - Hideki Origasa
- Division of Biostatistics and Clinical Epidemiology, University of Toyama, Toyama, Japan
| | - on behalf of the J-RHYTHM Registry Investigators
- Department of Internal Medicine and Cardiology, Nippon Medical School Tama-Nagayama Hospital, Tokyo, Japan
- Saiseikai Toyama Hospital, Toyama, Japan
- Minamihachioji Hospital, Tokyo, Japan
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine, Aomori, Japan
- Saiseikai Kumamoto Hospital, Kumamoto, Japan
- The Cardiovascular Institute, Tokyo, Japan
- Division of Biostatistics and Clinical Epidemiology, University of Toyama, Toyama, Japan
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Renal dysfunction and long-term clinical outcomes in patients with venous thromboembolism: From the COMMAND VTE Registry. Thromb Res 2020; 187:39-47. [PMID: 31951937 DOI: 10.1016/j.thromres.2020.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/29/2019] [Accepted: 01/08/2020] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Patients with renal dysfunction are at high risk for developing venous thromboembolism (VTE). However, the impact of renal dysfunction on recurrent VTE remains to be clarified. We assessed the relationship between estimated glomerular filtration rate (eGFR) at diagnosis and long-term clinical outcomes in VTE patients. MATERIALS AND METHODS The COMMAND VTE Registry is a multicenter registry enrolling consecutive patients with acute symptomatic VTE among 29 centers in Japan between January 2010 and August 2014. Patients with available creatinine values (N = 2829) were divided into the reference eGFR (≥60 mL/min/1.73 m2) group (N = 1760) and the low eGFR (<60 mL/min/1.73 m2) group (N = 1069). The low eGFR group was further subdivided into the moderately low eGFR (30-59 mL/min/1.73 m2) group (N = 898) and very low eGFR (<30 mL/min/1.73 m2) group (N = 171). RESULTS The low eGFR group was independently associated with the increased risk for recurrent VTE (adjusted HR 1.55, 95%CI 1.15-2.08). When the low eGFR group was subdivided into the moderately low and very low eGFR groups, the risk for recurrent VTE increased with decreasing eGFR (adjusted HR 1.43, 95%CI 1.04-1.95, and adjusted HR 2.54, 95%CI 1.42-4.28). The risk for major bleeding was higher in the very low eGFR group, but not in the moderately low eGFR group (adjusted HR 1.70, 95%CI 1.06-2.61, and adjusted HR 0.85, 95%CI 0.73-1.28). CONCLUSIONS Renal dysfunction measured by eGFR was associated with an increased risk for recurrent VTE, which was more prominent in severe renal dysfunction. Severe renal dysfunction was also associated with a higher risk for major bleeding.
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Kodani E, Atarashi H, Inoue H, Okumura K, Yamashita T, Origasa H. Impact of creatinine clearance on outcomes in patients with non-valvular atrial fibrillation: a subanalysis of the J-RHYTHM Registry. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2019; 4:59-68. [PMID: 28950373 PMCID: PMC5862022 DOI: 10.1093/ehjqcco/qcx032] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 08/31/2017] [Indexed: 11/19/2022]
Abstract
Aims To clarify the influence of renal function on adverse outcomes in patients with non-valvular atrial fibrillation (NVAF), a post hoc analysis of the J-RHYTHM Registry was performed. Methods and results A consecutive series of outpatients with atrial fibrillation (AF) were enrolled from 158 institutions and followed for 2 years or until the occurrence of an event. Among 7406 patients with non-valvular AF, 6052 patients (69.8 ± 10.0 years, 71.2% men) with creatinine clearance (CrCl) value at baseline were divided into four groups according to CrCl level (<30, 30–49.9, 50–79.9, and ≥80 mL/min). Patients with CrCl <80 mL/min showed increased incidence of thromboembolism, major haemorrhage, all-cause and cardiovascular death, and composite events as compared with patients with CrCl ≥80 mL/min. After adjustment for multiple confounders, lower CrCl values emerged as independent predictors for thromboembolism [CrCl 30–49.9, hazard ratio (HR) 2.27, 95% confidence interval (CI) 1.09–4.72, P = 0.029; and CrCl 50–79.9, HR 1.99, 95% CI 1.07–3.72, P = 0.030] and all-cause death (CrCl <30, HR 6.44, 95% CI 3.03–13.7, P < 0.001; and CrCl 30–49.9, HR 3.14, 95% CI 1.54–6.41, P = 0.002), with CrCl ≥80 mL/min serving as a reference, whereas not for major haemorrhage. Warfarin treatment was associated with lower rates of composite events in patients with lower CrCl values of <80 mL/min. Conclusion Renal impairment was an independent predictor of adverse clinical outcomes except for major haemorrhage in Japanese patients with non-valvular AF. Warfarin was associated with lower rates of composite events in patients with lower CrCl values. Clinical Trial Registration: http://www.umin.ac.jp/ctr/. Unique identifier: UMIN000001569.
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Affiliation(s)
- Eitaro Kodani
- Department of Internal Medicine and Cardiology, Nippon Medical School, Tama-Nagayama Hospital, 1-7-1 Nagayama, Tama-shi, Tokyo 206-8512, Japan
| | - Hirotsugu Atarashi
- Department of Internal Medicine and Cardiology, Nippon Medical School, Tama-Nagayama Hospital, 1-7-1 Nagayama, Tama-shi, Tokyo 206-8512, Japan
| | - Hiroshi Inoue
- Saiseikai Toyama Hospital, 33-1 Kusunoki, Toyama-shi, Toyama 931-8533, Japan
| | - Ken Okumura
- Saiseikai Kumamoto Hospital, 5-3-1 Chikami, Minami-ku, Kumamoto-shi, Kumamoto 861-4193, Japan
| | - Takeshi Yamashita
- The Cardiovascular Institute, 3-2-19 Nishiazabu, Minato-Ku, Tokyo 106-0031, Japan
| | - Hideki Origasa
- Division of Biostatistics and Clinical Epidemiology, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, 2630 Sugitani, Toyama-shi, Toyama 930-0194, Japan
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Inoue H, Kodani E, Atarashi H, Okumura K, Yamashita T, Origasa H. Renal Dysfunction Affects Anticoagulation Control With Warfarin and Outcomes in Japanese Elderly Patients With Non-Valvular Atrial Fibrillation. Circ J 2018; 82:2277-2283. [PMID: 29984788 DOI: 10.1253/circj.cj-18-0242] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND It is unclear whether renal dysfunction affects warfarin control in patients with non-valvular atrial fibrillation (NVAF). Methods and Results: Using a dataset from the J-RHYTHM Registry, time in therapeutic range (TTR) of the international normalized ratio (INR) of prothrombin time, and creatinine clearance (CrCl) were determined in elderly patients aged ≥70 years. Target INR values were 1.6-2.6 following Japanese guidelines. Incidences of thromboembolism, major hemorrhage, and all-cause death were determined over 2 years. Of 7,406 NVAF patients enrolled in the registry, 2,782 elderly patients (mean age, 75 years) had data for CrCl measured at baseline and TTR. TTR values were lower in the lower CrCl groups (P<0.001 for trend). CrCl <30 mL/min was independently associated with TTR <65% (odds ratio, 1.49; 95% confidence interval, 1.13-1.95; P=0.004). In the multivariate analysis, TTR <65% was independently associated with thromboembolism (hazard ratio, 2.26; 95% confidence interval, 1.37-3.72; P=0.001), but CrCl was not (CrCl <30 mL/min, 1.68, 0.41-6.85, P=0.473). However, CrCl <30 mL/min and TTR <65% were independently associated with all-cause death (5.32, 1.56-18.18, P=0.008 and 1.60, 1.07-2.38, P=0.022, respectively) and the composite event (thromboembolism, major hemorrhage and all-cause death) (2.03, 1.10-3.76, P=0.024 and 1.58, 1.22-2.04, P=0.001, respectively). CONCLUSIONS Elderly NVAF patients with renal dysfunction had poor warfarin control, which was associated with higher risk of thromboembolism and all-cause death.
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Affiliation(s)
| | - Eitaro Kodani
- Department of Internal Medicine, Nippon Medical School Tama-Nagayama Hospital
| | - Hirotsugu Atarashi
- Department of Internal Medicine, Nippon Medical School Tama-Nagayama Hospital
| | - Ken Okumura
- Department of Cardiology, Saiseikai Kumamoto Hospital
| | | | - Hideki Origasa
- Division of Biostatistics and Clinical Epidemiology, University of Toyama, Graduate School of Medicine
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Goldhaber SZ, Schulman S, Eriksson H, Feuring M, Fraessdorf M, Kreuzer J, Schüler E, Schellong S, Kakkar A. Dabigatran versus Warfarin for Acute Venous Thromboembolism in Elderly or Impaired Renal Function Patients: Pooled Analysis of RE-COVER and RE-COVER II. Thromb Haemost 2017; 117:2045-2052. [PMID: 29202209 DOI: 10.1160/th17-03-0176] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 07/13/2017] [Indexed: 11/05/2022]
Abstract
Management of acute venous thromboembolism (VTE) with anticoagulants in elderly patients and those with chronic kidney disease poses special challenges. The RE-COVER and RE-COVER II trials showed that dabigatran 150 mg twice daily was as effective as warfarin over 6 months in preventing recurrent VTE, with a lower bleeding risk. We now assess the effects of old age and renal impairment (RI) on pooled trial outcomes in 5,107 patients: 4,504 aged <75 years and 603 aged ≥75 years. The primary efficacy outcome was symptomatic VTE/VTE-related death. Safety outcomes were centrally adjudicated major bleeding events (MBEs), MBEs or clinically relevant non-major bleeding events (MBEs/CRBEs) and any bleeds. Baseline renal function was categorized as normal, mild RI or moderate RI. A total of 3,698 had normal renal function and 1,100 and 237 had mild and moderate RI, respectively (23 patients with severe RI and 49 with missing creatinine clearance data were not included). For dabigatran, VTE/VTE-related death decreased from 3.1% (normal renal function) to 1.9% for mild RI and to 0.0% for moderate RI. For warfarin, the event rates were 2.6, 1.6 and 4.1%, respectively. Overall, major bleeding increased with increasing RI (p = 0.0037) and with age (p = 0.4350), with no apparent difference between the dabigatran and warfarin patients. Dabigatran shows better efficacy than warfarin in RI and in the elderly patients, probably because of an increase in the concentration of dabigatran. However, bleeding risk increases with both dabigatran and warfarin in the presence of RI.
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Affiliation(s)
- Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Sam Schulman
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Henry Eriksson
- Department of Medicine, Sahlgrenska University Hospital-Östra, Gothenburg, Sweden
| | - Martin Feuring
- Boehringer Ingelheim GmbH & Co KG, Ingelheim am Rhein, Germany
| | | | - Jörg Kreuzer
- Boehringer Ingelheim GmbH & Co KG, Ingelheim am Rhein, Germany
| | - Elke Schüler
- Biostatistics Division, HMS Analytical Software GmbH, Heidelberg, Germany
| | | | - Ajay Kakkar
- Thrombosis Research Institute and University College London, London, United Kingdom
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Hirai T, Hamada Y, Geka Y, Kuwana S, Hirai K, Ishibashi M, Fukaya Y, Kimura T. A retrospective study on the risk factors for bleeding events in warfarin therapy, focusing on renal function. Eur J Clin Pharmacol 2017; 73:1491-1497. [DOI: 10.1007/s00228-017-2316-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 07/28/2017] [Indexed: 12/15/2022]
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Fukaya H, Niwano S, Oikawa J, Nishinarita R, Horiguchi A, Nakamura H, Fujiishi T, Igarashi T, Ishizue N, Yoshizawa T, Satoh A, Kishihara J, Murakami M, Ako J. Safety of low-dose dabigatran in patients with atrial fibrillation and mild renal insufficiency. J Cardiol 2017; 69:591-595. [DOI: 10.1016/j.jjcc.2016.05.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 04/15/2016] [Accepted: 05/06/2016] [Indexed: 01/06/2023]
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11
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Hijazi Z, Oldgren J, Siegbahn A, Wallentin L. Application of Biomarkers for Risk Stratification in Patients with Atrial Fibrillation. Clin Chem 2017; 63:152-164. [DOI: 10.1373/clinchem.2016.255182] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 09/01/2016] [Indexed: 12/13/2022]
Abstract
Abstract
BACKGROUND
Atrial fibrillation is the most common sustained arrhythmia and an important contributor to cardiovascular morbidity and mortality. Several strategies have been proposed for prediction of outcomes and individualization of treatments to better balance the benefits of stroke prevention and risks of bleeding during anticoagulation.
CONTENT
The availability of analytically more specific and sensitive methods to measure circulating biomarkers of cellular and organ stress and dysfunction has led to testing of their utility in several cardiovascular conditions. In patients with atrial fibrillation, biomarkers of myocardial injury (troponin) and cardiovascular stress and dysfunction (natriuretic peptides, growth differentiation factor 15), myocardial fibrosis (galectin-3), renal dysfunction (creatinine, cystatin C), inflammation (C-reactive protein, cytokines) and coagulation activity (d-dimer) have been found associated with underlying pathophysiology, clinical outcomes and effects of treatment. Measurements of these markers might therefore expand the understanding of the pathophysiology, improve risk assessment and optimize treatment in individual patients with atrial fibrillation.
SUMMARY
Biomarkers for risk stratification have potential roles as tools for evaluation of patients with atrial fibrillation and for selection of the best treatment strategies to prevent stroke, major bleeding, and mortality.
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Affiliation(s)
- Ziad Hijazi
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center (UCR), Uppsala University, Uppsala, Sweden
| | - Jonas Oldgren
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center (UCR), Uppsala University, Uppsala, Sweden
| | - Agneta Siegbahn
- Uppsala Clinical Research Center (UCR), Uppsala University, Uppsala, Sweden
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center (UCR), Uppsala University, Uppsala, Sweden
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12
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Labaf A, Grzymala-Lubanski B, Själander A, Svensson PJ, Stagmo M. Glomerular filtration rate and association to stroke, major bleeding, and death in patients with mechanical heart valve prosthesis. Am Heart J 2015; 170:559-65. [PMID: 26385040 DOI: 10.1016/j.ahj.2015.06.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 06/16/2015] [Indexed: 11/16/2022]
Abstract
AIMS The impact of estimated glomerular filtration rate (eGFR) on adverse events in patients with mechanical heart valves (MHVs) is unknown. We analyzed the independent association of eGFR and thromboembolism (TE), major bleeding, and mortality in patients with MHV in an observational cohort study. METHODS AND RESULTS All patients (n = 520) with MHV replacement on anticoagulation treatment were followed up prospectively regarding TE, major bleeding, and death at 2 anticoagulation centers during 2008 to 2011. The mean age was 69 years, 72% with aortic valve replacement, and time in therapeutic range 2.0 to 4.0 was 91%. The incidence of the combined end point of major bleeding, TE, and death increased sharply with each decreasing eGFR stratum: 5.5, 8.4, 16, and 32 per 100 patient-years for eGFR >60, 45 to 60, 30 to 45, and <30 mL/min per 1.73 m(2), respectively. After multivariate adjustment for comorbidities, every unit decrease in eGFR increased the risk of major bleeding by 2%, death by 3%, and the combined end point by 1%. There was no association between eGFR and TE. There was an increased proportion of international normalized ratio >3.0 and >4.0 and decreasing time in therapeutic range for each decreasing eGFR stratum (P < .001 for trend). The hazard ratios of the combined end point for eGFR <30, 30 to 45, and 45 to 60 mL/min per 1.73 m(2) were 3.2 (95% CI 1.8-5.6), 1.5 (95% CI 0.9-2.5), and 0.9 (95% CI 0.6-1.5), respectively, compared to eGFR >60 mL/min per 1.73 m(2). CONCLUSION In patients with MHV on anticoagulation, eGFR is an independent predictor of major bleeding and death and not TE.
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Affiliation(s)
- Ashkan Labaf
- Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Cardiology, Skåne University Hospital, Malmö, Sweden.
| | | | - Anders Själander
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Peter J Svensson
- Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Coagulation disorders, Skåne University Hospital, Malmö, Sweden
| | - Martin Stagmo
- Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Cardiology, Skåne University Hospital, Malmö, Sweden
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De Vriese AS, Caluwé R, Bailleul E, De Bacquer D, Borrey D, Van Vlem B, Vandecasteele SJ, Emmerechts J. Dose-Finding Study of Rivaroxaban in Hemodialysis Patients. Am J Kidney Dis 2015; 66:91-8. [DOI: 10.1053/j.ajkd.2015.01.022] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 01/22/2015] [Indexed: 11/11/2022]
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14
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Khouri Y, Stephens T, Ayuba G, AlAmeri H, Juratli N, McCullough PA. Understanding and Managing Atrial Fibrillation in Patients with Kidney Disease. J Atr Fibrillation 2015; 7:1069. [PMID: 27957157 DOI: 10.4022/jafib.1069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 03/21/2015] [Accepted: 03/28/2015] [Indexed: 01/21/2023]
Abstract
Chronic kidney disease (CKD) is on the rise due to the increased rate of related comorbidities such as diabetes and hypertension. Patients with CKD are at higher risk of cardiovascular events and atrial fibrillation is more common in this patient population. It is estimated that the prevalence of chronic atrial fibrillation in patients with CKD is two to three times higher than general population. Furthermore, patients with CKD are less likely to stay in sinus rhythm. Atrial fibrillation presents a major burden in this population due to difficult treatment decisions in the setting of a lack of evidence from randomized clinical trials. Patients with CKD have higher risk of stroke with more than half having a CHADS2 score ≥ 2. Anticoagulation have been shown to significantly decrease embolic stroke risk, however bleeding complications such as hemorrhagic stroke is twofold higher with warfarin. Although newer novel anticoagulation drugs have shown promise with lower intracranial hemorrhage risk in comparison to warfarin, lack clinical trial data in CKD and the unavailability of an antidote remains an issue. In this review, we discuss the treatment options available including anticoagulation and the evidence behind them in patients with chronic kidney disease suffering from atrial fibrillation.
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Affiliation(s)
- Yazan Khouri
- Oakwood Health System, Oakwood Hospital and Medical Center, Department of Cardiovascular Medicine, Dearborn, MI
| | - Tiona Stephens
- Oakwood Health System, Oakwood Hospital and Medical Center, Department of Cardiovascular Medicine, Dearborn, MI
| | - Gloria Ayuba
- Oakwood Health System, Oakwood Hospital and Medical Center, Department of Cardiovascular Medicine, Dearborn, MI
| | - Hazim AlAmeri
- Oakwood Health System, Oakwood Hospital and Medical Center, Department of Cardiovascular Medicine, Dearborn, MI
| | - Nour Juratli
- Oakwood Health System, Oakwood Hospital and Medical Center, Department of Cardiovascular Medicine, Dearborn, MI
| | - Peter A McCullough
- Baylor University Medical Center, Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, TX, The Heart Hospital, Plano, TX
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15
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Hemorrhage as a life-threatening complication after valve replacement in end-stage renal disease patients. Gen Thorac Cardiovasc Surg 2015; 63:386-94. [PMID: 25893900 DOI: 10.1007/s11748-015-0551-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 04/13/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Hemodialysis patients have an increased risk of hemorrhage compared to other patients. This study reports the frequencies of hemorrhage and its impact on the survival of hemodialysis patients after valve replacement. METHODS A total of 77 consecutive dialysis patients who underwent prosthetic valve surgery from 1991 to 2011 were retrospectively reviewed. Their mean age was 65.8 ± 9.2 years. Forty-three patients (56%) were male. Fifty-nine patients (77%) had aortic valve replacement, and 23 patients (30%) had mitral valve replacement. Bioprosthetic valves were used in 17 patients (22%). RESULTS There were seven in-hospital mortalities (9.1%). The overall estimated Kaplan-Meier survival after 3, 5 and 7 years was 66.6 ± 5.6, 51.1 ± 6.3 and 34.4 ± 6.8%, respectively. Seventeen (22%) bleeding events were observed (5.9% per patient-years) in the follow-up period. Six of the nine patients with cerebral hemorrhages and two of the six with gastrointestinal hemorrhages died. There were no differences in the frequencies of hemorrhage between the patients treated with bioprostheses and mechanical valves. CONCLUSIONS This study found that 22% of dialysis patients had hemorrhagic events after valve replacement, and approximately half of them died. Particularly, cerebral hemorrhage was fatal and two thirds of the patients died. So we should meditate the methods to reduce hemorrhage. Therefore, new methods to reduce the risk of hemorrhage are urgently needed.
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Efficacy and safety of vitamin K-antagonists (VKA) for atrial fibrillation in non-dialysis dependent chronic kidney disease. PLoS One 2014; 9:e94420. [PMID: 24817475 PMCID: PMC4015895 DOI: 10.1371/journal.pone.0094420] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 03/16/2014] [Indexed: 11/19/2022] Open
Abstract
Background Essential information regarding efficacy and safety of vitamin K-antagonists (VKA) treatment for atrial fibrillation (AF) in non-dialysis dependent chronic kidney disease (CKD) is still lacking in current literature. The aim of our study was to compare the risks of stroke or transient ischemic attack (TIA) and major bleeds between patients without CKD (eGFR >60 ml/min), and those with moderate (eGFR 30–60 ml/min), or severe non-dialysis dependent CKD (eGFR <30 ml/min). Methods We included 300 patients without CKD, 294 with moderate, and 130 with severe non-dialysis dependent CKD, who were matched for age and sex. Uni- and multivariate Cox regression analyses were performed reporting hazard ratios (HRs) for the endpoint of stroke or TIA and the endpoint of major bleeds as crude values and adjusted for comorbidity and platelet-inhibitor use. Results Overall, 6.2% (45/724, 1.7/100 patient years) of patients developed stroke or TIA and 15.6% (113/724, 4.8/100 patient years) a major bleeding event. Patients with severe CKD were at high risk of stroke or TIA and major bleeds during VKA treatment compared with those without renal impairment, HR 2.75 (95%CI 1.25–6.05) and 1.66 (95%CI 0.97–2.86), or with moderate CKD, HR 3.93(1.71–9.00) and 1.86 (95%CI 1.08–3.21), respectively. These risks were similar for patients without and with moderate CKD. Importantly, both less time spent within therapeutic range and high INR-variability were associated with increased risks of stroke or TIA and major bleeds in severe CKD patients. Conclusions VKA treatment for AF in patients with severe CKD has a poor safety and efficacy profile, likely related to suboptimal anticoagulation control. Our study findings stress the need for better tailored individualised anticoagulant treatment approaches for patients with AF and severe CKD.
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Chao TF, Chiang CE, Chen SA. Stroke in Atrial Fibrillation - Long-term Follow-up of Cardiovascular Events. Arrhythm Electrophysiol Rev 2013; 2:105-8. [PMID: 26835049 DOI: 10.15420/aer.2013.2.2.105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 08/28/2013] [Indexed: 11/04/2022] Open
Abstract
The incidence of atrial fibrillation (AF) was around 1.5 per 1000 person-years in Taiwan. Systemic thromboembolism is the most severe complication of AF. Risk stratification and adequate thromboembolism prophylaxis is the cornerstone of treatment in AF patients. The CHA2DS2-VASc score is powerful in selecting "truly low-risk" patients who are not necessary to receive anticoagulation therapies. It is also useful in predicting thromboembolic events and mortality for patients undergoing AF ablation. Recently, more and more biomarkers and imaging parameters were reported to be associated with adverse events in AF patients. How could these biomarkers and imaging tools change the current strategy of stroke prevention in AF deserves further investigations.
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Affiliation(s)
- Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University
| | - Chern-En Chiang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University; General Clinical Research Center, Taipei Veterans General Hospital; Department of Medical Research and Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University
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Abstract
Cardiac events are the major cause of death in hemodialysis patients. Because of the paucity of randomized clinical trials (RCTs) in hemodialysis patients, most cardiovascular therapies in this population are based on observational studies or results extrapolated from studies that excluded hemodialysis patients. However, associations discovered in observational studies do not prove causality, and these studies often report surrogate outcomes rather than clinical end points. Furthermore, interventions that show effectiveness in the general population may have drastically different outcomes and side effect profiles in hemodialysis patients. This review discusses the results of RCTs undertaken recently to evaluate cardiovascular therapies in hemodialysis patients and emphasizes clinically relevant outcomes. Although some interventions have produced similar outcomes in hemodialysis patients and the general population, others have not, suggesting that the management of cardiovascular disease in hemodialysis patients may require strategies that differ from the best practice guidelines applied to general population.
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Affiliation(s)
- Michael Allon
- Division of Nephrology, University of Alabama, Birmingham, Alabama
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Ng KP, Edwards NC, Lip GY, Townend JN, Ferro CJ. Atrial Fibrillation in CKD: Balancing the Risks and Benefits of Anticoagulation. Am J Kidney Dis 2013; 62:615-32. [PMID: 23746378 DOI: 10.1053/j.ajkd.2013.02.381] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Accepted: 02/21/2013] [Indexed: 12/20/2022]
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20
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Sood MM, Komenda P, Tangri N. Anticoagulation in patients with kidney disease: one size does not fit all. Thromb Res 2013; 131:469-71. [PMID: 23518011 DOI: 10.1016/j.thromres.2013.02.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 02/15/2013] [Accepted: 02/20/2013] [Indexed: 11/24/2022]
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