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Navalha DDP, Felix N, Nogueira A, Clemente M, Marinho AD, Ferreira ROM, Pasqualotto E, Dagostin CS, Pinto LCS, Fernandes GC. Direct oral anticoagulants versus vitamin K antagonists in patients with atrial fibrillation on chronic hemodialysis: a meta-analysis of randomized controlled trials. Int Urol Nephrol 2024; 56:2001-2010. [PMID: 38153665 DOI: 10.1007/s11255-023-03889-3] [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: 07/21/2023] [Accepted: 11/14/2023] [Indexed: 12/29/2023]
Abstract
PURPOSE Patients with atrial fibrillation (AF) and end-stage renal disease on chronic hemodialysis are at risk for thromboembolic and bleeding events. We aimed to perform a meta-analysis to evaluate the safety and efficacy of direct oral anticoagulants (DOACs) compared with vitamin K antagonists (VKAs) in this population. METHODS We systematically searched PubMed, Excerpta Medica Database (EMBASE) and Cochrane Library for randomized controlled trials (RCTs) comparing DOACs with VKAs in patients with AF on chronic hemodialysis from inception to February 2023 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Outcomes were reported using risk ratios (RRs) with 95% confidence intervals (CIs). Statistical analyses were performed using R version 4.2.2. RESULTS We selected three RCTs including 341 patients, of whom 176 (51.6%) were randomized to DOACs. Follow-up ranged from 174 days to 3.38 years. There was no significant difference between groups in terms of cardiovascular mortality (RR 1.34; 95% CI 0.69-2.60; p = 0.39), all-cause mortality (RR 0.96; 95% CI 0.72-1.27; p = 0.77), ischemic/uncertain type of stroke or transient ischemic attack (RR 0.50; 95% CI 0.19-1.35; p = 0.17), or major or life-threatening bleeding (RR 0.70; 95% CI 0.39-1.25; p = 0.22). CONCLUSION In this meta-analysis of three RCTs, no significant difference was observed between DOACs and VKAs in cardiovascular mortality, all-cause mortality, ischemic/uncertain type of stroke or transient ischemic attack, or major or life-threatening bleeding in patients with AF on chronic hemodialysis.
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Affiliation(s)
| | - Nicole Felix
- Federal University of Campina Grande, Campina Grande, Brazil
| | - Alleh Nogueira
- Bahiana School of Medicine and Public Health, Salvador, Brazil
| | | | - Alice D Marinho
- Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
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Wing SL, Mavrakanas TA, Harel Z. Oral Anticoagulation Use in Individuals With Atrial Fibrillation and Chronic Kidney Disease: A Review. Semin Nephrol 2024:151517. [PMID: 38744617 DOI: 10.1016/j.semnephrol.2024.151517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Atrial fibrillation (AF) is highly prevalent in patients with chronic kidney disease (CKD). It is associated with an increased risk of stroke, which increases as kidney function declines. In the general population and in those with a moderate degree of CKD (creatinine clearance 30-50 mL/min), the use of oral anticoagulation to decrease the risk of stroke has been the standard of care based on a favorable risk-benefit profile that had been established in seminal randomized controlled trials. However, evidence regarding the use of oral anticoagulants for stroke prevention is less clear in patients with severe CKD (creatinine clearance <30 mL/min) and those receiving maintenance dialysis, as these individuals were excluded from such large randomized controlled trials. Nevertheless, the direct oral anticoagulants have invariably usurped vitamin K antagonists as the preferred choice for oral anticoagulation among patients with AF across all strata of CKD based on their well-defined safety and efficacy and multiple pharmacokinetic benefits (e.g., less drug-drug interactions). This review summarizes the current literature on the role of oral anticoagulation in the management of AF among patients with CKD and highlights current deficiencies in the evidence base and how to overcome them.
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Affiliation(s)
- Sara L Wing
- Division of Nephrology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Thomas A Mavrakanas
- Division of Nephrology, Department of Medicine, McGill University Health Centre and Research Institute, Montreal, Canada
| | - Ziv Harel
- Division of Nephrology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Canada.
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Marubayashi N, Kakeshita K, Imamura T. How to demonstrate the prognostic impact of interdialytic home blood pressure variability in dialytic patients. Clin Cardiol 2024; 47:e24279. [PMID: 38775272 PMCID: PMC11110098 DOI: 10.1002/clc.24279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 04/29/2024] [Indexed: 05/25/2024] Open
Affiliation(s)
| | - Kota Kakeshita
- Second Department of Internal MedicineUniversity of ToyamaToyamaJapan
| | - Teruhiko Imamura
- Second Department of Internal MedicineUniversity of ToyamaToyamaJapan
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Ballegaard ELF, Lindhard K, Lindhardt M, Peters CD, Thomsen Nielsen F, Tietze IN, Borg R, Boesby L, Bertelsen MC, Brøsen JMB, Cibulskyte-Ninkovic D, Rantanen JM, Mose FH, Kampmann JD, Nielsen AS, Breinholt JK, Kofod DH, Bressendorff I, Clausen PV, Lange T, Køber L, Kamper AL, Bang CNF, Torp-Pedersen C, Hansen D, Grove EL, Gislason G, Dam Jensen J, Olesen JB, Hornum M, Rix M, Schou M, Carlson N. Protocol for a randomised controlled trial comparing warfarin with no oral anticoagulation in patients with atrial fibrillation on chronic dialysis: the Danish Warfarin-Dialysis (DANWARD) trial. BMJ Open 2024; 14:e081961. [PMID: 38413147 PMCID: PMC10900386 DOI: 10.1136/bmjopen-2023-081961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 02/12/2024] [Indexed: 02/29/2024] Open
Abstract
INTRODUCTION Atrial fibrillation is highly prevalent in patients on chronic dialysis. It is unclear whether anticoagulant therapy for stroke prevention is beneficial in these patients. Vitamin K-antagonists (VKA) remain the predominant anticoagulant choice. Importantly, anticoagulation remains inconsistently used and a possible benefit remains untested in randomised clinical trials comparing oral anticoagulation with no treatment in patients on chronic dialysis. The Danish Warfarin-Dialysis (DANWARD) trial aims to investigate the safety and efficacy of VKAs in patients with atrial fibrillation on chronic dialysis. The hypothesis is that VKA treatment compared with no treatment is associated with stroke risk reduction and overall benefit. METHODS AND ANALYSIS The DANWARD trial is an investigator-initiated trial at 13 Danish dialysis centres. In an open-label randomised clinical trial study design, a total of 718 patients with atrial fibrillation on chronic dialysis will be randomised in a 1:1 ratio to receive either standard dose VKA targeting an international normalised ratio of 2.0-3.0 or no oral anticoagulation. Principal analyses will compare the risk of a primary efficacy endpoint, stroke or transient ischaemic attack and a primary safety endpoint, major bleeding, in patients allocated to VKA treatment and no treatment, respectively. The first patient was randomised in October 2019. Patients will be followed until 1 year after the inclusion of the last patient. ETHICS AND DISSEMINATION The study protocol was approved by the Regional Research Ethics Committee (journal number H-18050839) and the Danish Medicines Agency (case number 2018101877). The trial is conducted in accordance with the Helsinki declaration and standards of Good Clinical Practice. Study results will be disseminated to participating sites, at research conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBERS NCT03862859, EUDRA-CT 2018-000484-86 and CTIS ID 2022-502500-75-00.
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Affiliation(s)
- Ellen Linnea Freese Ballegaard
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Kristine Lindhard
- Department of Nephrology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Morten Lindhardt
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Internal Medicine 1, Holbæk Hospital, Holbæk, Denmark
| | - Christian Daugaard Peters
- Dept. of Clinical Medicine, Aarhus University, Aarhus N, Denmark
- Department of Renal Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Finn Thomsen Nielsen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Medicine, Bornholms Hospital, Ronne, Denmark
| | | | - Rikke Borg
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Lene Boesby
- Department of Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Marianne Camilla Bertelsen
- Department of Endocrinology and Nephrology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Julie Maria Bøggild Brøsen
- Department of Endocrinology and Nephrology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | | | | | - Frank Holden Mose
- Department of Nephrology, Gødstrup Regional Hospital, Herning, Denmark
| | - Jan Dominik Kampmann
- Internal medicine, Hospital of Southern Jutland Sonderborg Branch, Sonderborg, Denmark
| | - Alice Skovhede Nielsen
- Department of Medicine, Esbjerg Hospital, University Hospital of Southern Denmark, Esbjerg, Denmark
| | - Johanne Kodal Breinholt
- Department of Clinical Biochemistry, Esbjerg Hospital, University Hospital of Southern Denmark, Esbjerg, Denmark
| | - Dea Haagensen Kofod
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Iain Bressendorff
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Nephrology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Peter Vilhelm Clausen
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Theis Lange
- Section of Biostatistics, University of Copenhagen, Kobenhavns, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anne-Lise Kamper
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Casper Niels Furbo Bang
- Department of Cardiology, Copenhagen University Hospital - Frederiksberg and Bispebjerg, Copenhagen, Denmark
| | | | - Ditte Hansen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Nephrology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Faculty of Health, Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
- The Danish Heart Foundation, Copenhagen, Denmark
| | - Jens Dam Jensen
- Department of Renal Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Mads Hornum
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Marianne Rix
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Morten Schou
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Nicholas Carlson
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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Joki N, Toida T, Nakata K, Abe M, Hanafusa N, Kurita N. Effect of atherosclerosis on the relationship between atrial fibrillation and ischemic stroke incidence among patients on hemodialysis. Sci Rep 2024; 14:1330. [PMID: 38225279 PMCID: PMC10789759 DOI: 10.1038/s41598-024-51439-3] [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: 10/03/2023] [Accepted: 01/04/2024] [Indexed: 01/17/2024] Open
Abstract
In patients undergoing hemodialysis, the impact of atrial fibrillation (AF) through cardiac thromboembolism on the development of ischemic stroke may be influenced by the severity of atherosclerosis present. However, there are no large-scale reports confirming whether the severity of atherosclerosis influences the relationship between AF and stroke development in patients requiring hemodialysis. We aimed to investigate the effects of atherosclerotic disease on the relationship between AF and new-onset ischemic stroke. This nationwide longitudinal study based on dialysis facilities across Japan used data collected from the Japanese Renal Data Registry at the end of 2019 and 2020. The exposure was AF at the end of 2019, identified using a resting 12-lead electrocardiography. The primary outcome was the incidence of cerebral infarction (CI) after 1 year. To examine whether the number of atherosclerotic diseases modified the association between AF and the outcome, we estimated the odds ratios (ORs) using a logistic regression model and then assessed the presence of global interaction using Wald test. Following the study criteria, data from 151,350 patients (mean age, 69 years; men, 65.2%; diabetic patients, 48.7%) were included in the final analysis. A total of 9841 patients had AF (prevalence, 6.5%). Between 2019 and 2020, 4967 patients (3.2%) developed ischemic stroke. The adjusted OR of AF for new-onset CI was 1.5, which showed a decreasing trend with an increasing number of atherosclerotic diseases; the interaction was not significant (P = 0.34). While age, diabetes mellitus, smoking, systolic blood pressure, and serum C-reactive protein concentration were positively associated with CI, intradialytic weight gain, body mass index, and serum albumin level were negatively associated. While we demonstrated the association between AF and new-onset CI among Japanese patients on hemodialysis, we failed to demonstrate the evidence that the association was attenuated with an increasing numbers of atherosclerotic complications.
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Affiliation(s)
- Nobuhiko Joki
- Division of Nephrology, Toho University Ohashi Medical Center, 2-22-36, Ohashi, Meguro-ku, Tokyo, 153-8515, Japan.
| | - Tatsunori Toida
- School of Pharmaceutical Sciences, Kyushu University of Health and Welfare, Miyazaki, Japan
- Department of Clinical Epidemiology, Graduate School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Kenji Nakata
- Division of Nephrology, Toho University Ohashi Medical Center, 2-22-36, Ohashi, Meguro-ku, Tokyo, 153-8515, Japan
| | - Masanori Abe
- Divisions of Nephrology, Hypertension, and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Norio Hanafusa
- Department of Blood Purification, Tokyo Women's Medical University, Tokyo, Japan
| | - Noriaki Kurita
- Department of Clinical Epidemiology, Graduate School of Medicine, Fukushima Medical University, Fukushima, Japan
- Department of Innovative Research and Education for Clinicians and Trainees (DiRECT), Fukushima Medical University Hospital, Fukushima, Japan
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Edmonston D, Grabner A, Wolf M. FGF23 and klotho at the intersection of kidney and cardiovascular disease. Nat Rev Cardiol 2024; 21:11-24. [PMID: 37443358 DOI: 10.1038/s41569-023-00903-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 07/15/2023]
Abstract
Cardiovascular disease is the leading cause of death in patients with chronic kidney disease (CKD). As CKD progresses, CKD-specific risk factors, such as disordered mineral homeostasis, amplify traditional cardiovascular risk factors. Fibroblast growth factor 23 (FGF23) regulates mineral homeostasis by activating complexes of FGF receptors and transmembrane klotho co-receptors. A soluble form of klotho also acts as a 'portable' FGF23 co-receptor in tissues that do not express klotho. In progressive CKD, rising circulating FGF23 levels in combination with decreasing kidney expression of klotho results in klotho-independent effects of FGF23 on the heart that promote left ventricular hypertrophy, heart failure, atrial fibrillation and death. Emerging data suggest that soluble klotho might mitigate some of these effects via several candidate mechanisms. More research is needed to investigate FGF23 excess and klotho deficiency in specific cardiovascular complications of CKD, but the pathophysiological primacy of FGF23 excess versus klotho deficiency might never be precisely resolved, given the entangled feedback loops that they share. Therefore, randomized trials should prioritize clinical practicality over scientific certainty by targeting disordered mineral homeostasis holistically in an effort to improve cardiovascular outcomes in patients with CKD.
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Affiliation(s)
- Daniel Edmonston
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Alexander Grabner
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Myles Wolf
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.
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Niehues P, Wolfes J, Wegner FK, Ellermann C, Rath B, Eckardt L. Use of direct oral anticoagulants in patients on chronic hemodialysis: Contemporary appraisal on the role for patients with atrial fibrillation. Trends Cardiovasc Med 2023:S1050-1738(23)00106-8. [PMID: 38043918 DOI: 10.1016/j.tcm.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 11/08/2023] [Accepted: 11/26/2023] [Indexed: 12/05/2023]
Abstract
Atrial fibrillation (AF) is common in patients with chronic kidney disease (CKD) undergoing hemodialysis and in this patient population, management in terms of oral anticoagulation (OAC) presents unique challenges due to the increased risk of both thromboembolic events and bleeding complications. The attributable risk of AF for stroke may differ from patients without CKD, raising the question if OAC is indicated at all. Historically, vitamin K antagonists (VKA) have been the standard treatment for anticoagulation in AF; however, direct oral anticoagulants (DOACs) have emerged as an alternative therapeutic option, whereby data from prospective randomised trials with hemodialysis patients is limited resulting in great variability of practice and guideline recommendations. This review summarizes existing data sources regarding the use and benefit of oral anticoagulation with VKA and DOAC in hemodialysis patients.
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Affiliation(s)
- Philipp Niehues
- Department of Cardiology II - Electrophysiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster 48149, Germany
| | - Julian Wolfes
- Department of Cardiology II - Electrophysiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster 48149, Germany
| | - Felix K Wegner
- Department of Cardiology II - Electrophysiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster 48149, Germany
| | - Christian Ellermann
- Department of Cardiology II - Electrophysiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster 48149, Germany
| | - Benjamin Rath
- Department of Cardiology II - Electrophysiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster 48149, Germany
| | - Lars Eckardt
- Department of Cardiology II - Electrophysiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster 48149, Germany.
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Abstract
Cardiovascular diseases are highly prevalent among patients on dialysis. For these diseases, antiplatelets and antithrombotic therapies including heparin, vitamin K antagonists, and direct oral anticoagulants, are being used. However, the benefit-risk balance of these therapies could differ for dialysis patients compared with the general population. This review article focuses on the bleeding risk associated with the use of heparin, antiplatelets, vitamin K antagonists, and direct oral anticoagulants in patients receiving hemodialysis.
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Affiliation(s)
| | - Pearl Pai
- Department of Medicine, University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong; Department of Medicine, University of Hong Kong Shenzhen Hospital, Shenzhen, China
| | - Wenjuan Zhu
- Department of Medicine, University of Hong Kong Shenzhen Hospital, Shenzhen, China
| | - Gurbey Ocak
- Department of Internal Medicine, Sint Antonius Hospital, Nieuwegein, The Netherlands
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Echefu G, Stowe I, Burka S, Basu-Ray I, Kumbala D. Pathophysiological concepts and screening of cardiovascular disease in dialysis patients. FRONTIERS IN NEPHROLOGY 2023; 3:1198560. [PMID: 37840653 PMCID: PMC10570458 DOI: 10.3389/fneph.2023.1198560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 08/10/2023] [Indexed: 10/17/2023]
Abstract
Dialysis patients experience 10-20 times higher cardiovascular mortality than the general population. The high burden of both conventional and nontraditional risk factors attributable to loss of renal function can explain higher rates of cardiovascular disease (CVD) morbidity and death among dialysis patients. As renal function declines, uremic toxins accumulate in the blood and disrupt cell function, causing cardiovascular damage. Hemodialysis patients have many cardiovascular complications, including sudden cardiac death. Peritoneal dialysis puts dialysis patients with end-stage renal disease at increased risk of CVD complications and emergency hospitalization. The current standard of care in this population is based on observational data, which has a high potential for bias due to the paucity of dedicated randomized clinical trials. Furthermore, guidelines lack specific guidelines for these patients, often inferring them from non-dialysis patient trials. A crucial step in the prevention and treatment of CVD would be to gain better knowledge of the influence of these predisposing risk factors. This review highlights the current evidence regarding the influence of advanced chronic disease on the cardiovascular system in patients undergoing renal dialysis.
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Affiliation(s)
- Gift Echefu
- Division of Cardiovascular Medicine, The University of Tennessee Health Science Center, Memphis, TN, United States
| | - Ifeoluwa Stowe
- Department of Internal Medicine, Baton Rouge General Medical Center, Baton Rouge, LA, United States
| | - Semenawit Burka
- Department of Internal Medicine, University of Texas Rio Grande Valley, McAllen, TX, United States
| | - Indranill Basu-Ray
- Department of Cardiology, Memphis Veterans Affairs (VA) Medical Center, Memphis, TN, United States
| | - Damodar Kumbala
- Nephrology Division, Renal Associates of Baton Rouge, Baton Rouge, LA, United States
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Law MM, Tan SJ, Wong MC, Toussaint ND. Atrial Fibrillation in Kidney Failure: Challenges in Risk Assessment and Anticoagulation Management. Kidney Med 2023; 5:100690. [PMID: 37547561 PMCID: PMC10403723 DOI: 10.1016/j.xkme.2023.100690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Abstract
Management of atrial fibrillation (AF) is a clinical conundrum in people with kidney failure. Stroke risk is disproportionately high, but clinicians have a limited armamentarium to improve outcomes in this population in whom there is a concurrently high bleeding risk. Direct oral anticoagulants may have a superior benefit-risk profile compared with vitamin K antagonists in people on hemodialysis. Although research has predominantly focused on identifying a safe and effective oral anticoagulation option to reduce stroke risk in people with kidney failure (and predominantly those on hemodialysis), it remains uncertain how clinicians discriminate between people who would derive net clinical benefit as opposed to net harm. The recommended CHA2DS2-VASc score cutoffs provide poor discriminatory value, and there is an urgent need to identify robust markers of thromboembolic risk in kidney failure. There is increasing data to challenge the prior dogma of risk equivalence across AF type, and the American Heart Association highlights moving beyond AF as a binary entity to consider the prognostic significance of AF burden. Implantable cardiac monitor studies reveal high rates and varied burden of subclinical and paroxysmal AF in people on hemodialysis. The association between AF burden and the proarrhythmic environment of hemodialysis with cyclical volume loading, offloading, and electrolyte changes is not well studied. We review the significance of AF burden as a contributor to thromboembolic risk, its potential as the missing link in risk assessment, and updated evidence for anticoagulation in people with kidney failure.
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Affiliation(s)
- Mandy M. Law
- Department of Nephrology, the Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Sven-Jean Tan
- Department of Nephrology, the Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Michael C.G. Wong
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Department of Cardiology, the Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Nigel D. Toussaint
- Department of Nephrology, the Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
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Kourtidou C, Tziomalos K. Epidemiology and Risk Factors for Stroke in Chronic Kidney Disease: A Narrative Review. Biomedicines 2023; 11:2398. [PMID: 37760839 PMCID: PMC10525494 DOI: 10.3390/biomedicines11092398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 08/21/2023] [Accepted: 08/24/2023] [Indexed: 09/29/2023] Open
Abstract
Patients with chronic kidney disease (CKD) have a higher risk ofboth ischemic and hemorrhagic stroke. This association appears to be partly independent from the higher prevalence of established risk factors for stroke in patients with CKD, including hypertension and atrial fibrillation. In the present review we aim to discuss the impact of CKD on the risk of stroke and stroke-related consequences, and explore the pathophysiology underpinning the increased risk of stroke in patients with CKD. We cover the clinical association between renal dysfunction and cerebrovascular disease including stroke, silent brain infarct, cerebral small vessel disease, microbleeds, and white matter hyperintensity, and discuss the underlying mechanisms.
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Affiliation(s)
- Christodoula Kourtidou
- Department of Nephrology, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636 Thessaloniki, Greece;
| | - Konstantinos Tziomalos
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636 Thessaloniki, Greece
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12
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Simic J, Mihajlovic M, Zec N, Kovacevic V, Marinkovic M, Mujovic N, Potpara T. The impact of anticoagulation therapy on kidney function in patients with atrial fibrillation and chronic kidney disease. Expert Rev Cardiovasc Ther 2023; 21:937-945. [PMID: 37842943 DOI: 10.1080/14779072.2023.2270909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/11/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION Atrial fibrillation (AF) and chronic kidney disease (CKD) are closely related. These diseases share common risk factors and are associated with increased risk of thromboembolic events. Choosing the appropriate oral anticoagulant therapy (OAC) in patients with AF and CKD is challenging. Deterioration of renal function is common in patients with AF treated with OACs, although not all OACs affect the kidneys equally. AREAS COVERED In this review, we aim to summarize the current knowledge of the prevention of thromboembolic events in patients with AF and CKD, focusing on the impact of specific OAC agents on renal function. EXPERT OPINION Consideration of OAC use is mandatory in patients with AF and CKD who are at increased risk of stroke or systemic embolism. Available evidence suggests that the use of non-vitamin K antagonist oral anticoagulants (NOACs) is associated with slower deterioration of renal function in comparison to Vitamin K antagonists (VKAs). Hence, a NOAC should be used in preference to VKAs in all NOAC-eligible patients with AF and CKD. Regarding patients with end-stage renal dysfunction and those on dialysis or renal replacement therapy, the use of NOAC should be considered in line with locally relevant formal recommendations.
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Affiliation(s)
- Jelena Simic
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Nevena Zec
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Vladan Kovacevic
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Milan Marinkovic
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Nebojsa Mujovic
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Tatjana Potpara
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
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Cho MS, Choi HO, Hwang KW, Kim J, Nam GB, Choi KJ. Clinical benefits and risks of anticoagulation therapy according to the degree of chronic kidney disease in patients with atrial fibrillation. BMC Cardiovasc Disord 2023; 23:209. [PMID: 37098477 PMCID: PMC10131393 DOI: 10.1186/s12872-023-03236-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 04/11/2023] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND The clinical benefits and risks of anticoagulation therapy in patients with chronic kidney disease (CKD) are still inconclusive. We describe the outcomes of patients with atrial fibrillation (AF) after anticoagulation therapy according to differences in creatinine clearance (CrCl). We also aimed to determine the patients who could benefit from anticoagulation therapy. METHODS This is a retrospective observational review of patients with AF who were managed at Asan Medical Center (Seoul, Korea) between January 1, 2006, and December 31, 2018. Patients were categorized into groups according to their baseline CrCl by Cockcroft-Gault equation and their outcomes were evaluated (CKD 1, ≥ 90 mL/min; CKD2, 60-89 mL/min; CKD3, 30-59 mL/min; CKD4, 15-29 mL/min; CKD 5, < 15 mL/min). The primary outcome was NACE (net adverse clinical events), defined as a composite of all-cause mortality, thromboembolic events, and major bleeding. RESULTS We identified 12,714 consecutive patients with AF (mean 64.6 ± 11.9 years, 65.3% male, mean CHA2DS2-VASc score 2.4 ± 1.6 points) between 2006 and 2017. In patients receiving anticoagulation therapy (n = 4447, 35.0%), warfarin (N = 3768, 84.7%) was used more frequently than NOACs (N = 673, 15.3%). There was a higher 3-year rate of NACE with renal function deterioration (14.8%, 18.6%, 30.3%, 44.0%, and 48.8% for CKD stages 1-5, respectively).The clinical benefit of anticoagulation therapy was most prominent in patients with CKD 1 (hazard ratio [HR] 0.49, 95% confidence interval [CI] 0.37-0.67), 2 (HR 0.64 CI 0.54-0.76), and 3 (HR 0.64 CI 0.54-0.76), but not in CKD 4 (HR 0.86, CI 0.57-1.28) and 5 (HR 0.81, CI 0.47-1.40). Among patients with CKD, the benefit of anticoagulation therapy was only evident in those with a high risk of embolism (CHA2DS2-VASc score ≥ 4, HR 0.25, CI 0.08-0.80). CONCLUSION Advanced CKD is associated with a higher risk of NACE. The clinical benefit of anticoagulation therapy was reduced with the increasing CKD stage.
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Affiliation(s)
- Min Soo Cho
- Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyung Oh Choi
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, 170, Jomaru-ro, Bucheon-si, Gyeonggi-do, 14584, Republic of Korea.
| | - Ki Won Hwang
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan, Republic of Korea
| | - Jun Kim
- Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Gi-Byoung Nam
- Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kee-Joon Choi
- Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Parada Barcia JA, Raposeiras Roubin S, Abu-Assi E, Erquicia PD, Lizancos Castro A, Lestón LR, Míguez JO, González Bermúdez I, Íñiguez-Romo A. Comparison of Stroke and Bleeding Risk Profile in Patients With Atrial Fibrillation and Chronic Kidney Disease. Am J Cardiol 2023; 196:31-37. [PMID: 37058875 DOI: 10.1016/j.amjcard.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 03/08/2023] [Accepted: 03/17/2023] [Indexed: 04/16/2023]
Abstract
Clinical decision making on anticoagulation in patients with chronic kidney disease with atrial fibrillation (AF) is challenging. The current strategies are based on small observational studies with conflicting results. This study explores the impact of glomerular filtration rate (GFR) in the embolic-hemorrhagic balance among a large cohort of patients with AF. The study cohort included 15,457 patients diagnosed with AF between January 2014 and April 2020. The risk of ischemic stroke and major bleeding was determined by competing risk regression. During a mean follow-up of 4.29 ± 1.82 years, 3,678 patients (23.80%) died, 850 (5.50%) had an ischemic stroke, and 961 (6.22%) had a major bleeding. The incidence of stroke and bleeding increased as baseline GFR decreased. Interestingly, in GFR <30 ml/min/1.73 m2, the bleeding risk was clearly higher than the embolic risk. As GFR decreased, anticoagulation was associated with an increased bleeding risk (subdistribution hazard ratio 1.700, 95% confidence interval [CI] 1.13 to 2.54, p = 0.009 for patients with GFR 30 to 59 ml/min/1.73 m2 and 2.00, 95% CI 0.77 to 5.21, p = 0.156 for subjects with <30 ml/min/1.73 m2 compared with those with GFR >60 ml/min/1.73 m2, respectively), but it was not associated with a decrease in embolic risk in patients with GFR <30 ml/min/1.73 m2 (subdistribution hazard ratio 1.91, 95% CI 0.73 to 5.04, p = 0.189) In GFR <30 ml/min/1.73 m2, the increase of major bleeding risk was higher than the increase of ischemic stroke risk, with a negative anticoagulation balance (greater increase in bleeding than reduction in embolism).
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Affiliation(s)
- José Antonio Parada Barcia
- Cardiology Department, University Hospital Alvaro Cunqueiro, Vigo, Spain; Medicine Department, University of Santiago de Compostela, Santiago, Spain
| | - Sergio Raposeiras Roubin
- Cardiology Department, University Hospital Alvaro Cunqueiro, Vigo, Spain; Cardiovascular Group, Health Research Institute Galicia Sur, Vigo, Spain; Cardiovascular Group, Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain.
| | - Emad Abu-Assi
- Cardiology Department, University Hospital Alvaro Cunqueiro, Vigo, Spain; Cardiovascular Group, Health Research Institute Galicia Sur, Vigo, Spain
| | | | | | | | - Juan Ocampo Míguez
- Cardiology Department, University Hospital Alvaro Cunqueiro, Vigo, Spain
| | | | - Andrés Íñiguez-Romo
- Cardiology Department, University Hospital Alvaro Cunqueiro, Vigo, Spain; Cardiovascular Group, Health Research Institute Galicia Sur, Vigo, Spain
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15
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Yang Z, Wang J, Yuan Y, Cheng T, Ren F, Wang S, Zhang Z. Application of rivaroxaban in patients with non-valvular atrial fibrillation and end-stage kidney disease: A systematic review and meta-analysis. Front Cardiovasc Med 2023; 10:1021959. [PMID: 36844734 PMCID: PMC9951003 DOI: 10.3389/fcvm.2023.1021959] [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: 08/18/2022] [Accepted: 01/17/2023] [Indexed: 02/10/2023] Open
Abstract
Background Nowadays, the number of patients with non-valvular atrial fibrillation (NVAF) complicated by end-stage renal disease (ESKD) is increasing. There are significant challenges in anticoagulation with prescription drugs because of the high risk of bleeding and embolism among these patients. However, no randomized controlled trials (RCTs) of warfarin in combination with any non-vitamin K oral anticoagulant (NOACs) have been performed in patients with baseline creatinine clearance (CrCl) <25 ml/min, which makes it difficult to justify the use of anticoagulants in such patients. Then, we aimed to collect and summarize all evidence to enable the anticoagulation of rivaroxaban, which is less cleared by the kidneys, in patients with severe renal insufficiency and to complement and improve the evidence on the use of rivaroxaban for anticoagulation. Methods The present systematic review and meta-analysis searched the databases of PubMed, Embase, the Cochrane Library, CNKI, CBM, and Google Scholar for relevant studies from inception to 1 June 2022, with the restriction of English and Chinese. Eligible cohort studies and RCTs that reported efficacy outcomes [composite of stroke and systemic embolism (SSE), ischemic stroke (ICS), and systemic embolization] or safety outcomes [major bleeding, intracranial hemorrhage (ICH), and gastrointestinal bleeding (GIB)] of rivaroxaban in NVAF patients with ESKD were enrolled. Two authors completed the data extraction and quality assessment work, respectively. The Cochrane Collaboration tool for assessing the risk of bias was used for RCTs, and the NEW-Castle Ottawa scale was used for study quality assessment for cohort studies. Dichotomous variables were calculated as risk factors with 95% confidence intervals (CIs), and meta-analysis was performed to probe the effect of research design, rivaroxaban dose, and controlled drug factors on outcomes. Results In total, three studies were included for meta-analysis, involving 6,071 NVAF patients with ESKD, and two studies were included for qualitative analysis. All included studies were at low risk of bias. A meta-analysis demonstrated that mix-dose rivaroxaban caused no statistical discrepancy in the occurrence of thrombotic and bleeding events when compared to the control group (embolism, LogOR: -0.64, 95% CI: -1.05 to -0.23, P:0.25; bleeding, LogOR: -0.33, 95% CI: -0.63 to -0.03, P:0.15), and low-dose rivaroxaban produced similar results (embolism, LogOR: -1.04, 95% CI: -2.15 to 0.07, P:0.61; bleeding, LogOR: -0.81, 95% CI: -1.19 to -0.44, P:0.93). Conclusion In this study, low-dose rivaroxaban (10 mg, once a day) may benefit more than warfarin in patients with NVAF and ESKD. Systematic review registration https://www.crd.york.ac.uk/prospero/#recordDetails, identifier CRD42022330973.
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Affiliation(s)
- Zhenzhen Yang
- Department of Pharmacy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jieya Wang
- Department of Pharmacy, The Sixth Affiliated Hospital of Kunming Medical University, Yuxi, China
| | - Ye Yuan
- Department of Pharmacy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Tian Cheng
- Department of Pharmacy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Feifei Ren
- Department of Pharmacy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Songsong Wang
- Department of Pharmacy, The Second Hospital of Hebei Medical University, Shijiazhuang, China,Department of Pharmacology, Hebei Medical University, Shijiazhuang, China, Songsong Wang, ; orcid.org/0000-0003-0528-7920
| | - Zhiqing Zhang
- Department of Pharmacy, The Second Hospital of Hebei Medical University, Shijiazhuang, China,*Correspondence: Zhiqing Zhang,
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16
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Impact of the 3% Oxygen Desaturation Index via Overnight Pulse Oximetry on Cardiovascular Events and Death in Patients Undergoing Hemodialysis: A Retrospective Cohort Study. J Clin Med 2023; 12:jcm12030858. [PMID: 36769506 PMCID: PMC9917943 DOI: 10.3390/jcm12030858] [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: 12/18/2022] [Revised: 01/12/2023] [Accepted: 01/19/2023] [Indexed: 01/24/2023] Open
Abstract
It is unclear whether the severity of sleep-disordered breathing (SDB) affects the risk of cardiovascular events and mortality in patients undergoing hemodialysis (HD). We determined the severity of SDB with the 3% oxygen desaturation index (ODI) via overnight pulse oximetry. This study was a retrospective cohort, observational study of 134 patients on maintenance HD at a single center. They were divided into four groups according to SDB severity (normal, mild, moderate, and severe), and were followed. The baseline characteristics of all patients were as follows: the median age was 67 (interquartile range, 59-75) years, 64.2% were men, 37.3% were diabetic, and the median duration of HD was 69 (29-132) months. During follow-up, major adverse cardiovascular events (MACEs) occurred in 71 patients and deaths in 60 (including 32 cardiovascular deaths). Severe SDB was an independent risk factor for MACEs (hazard ratio [HR] = 4.66, 95% confidence interval [CI] = 1.87-11.61, p = 0.001) and all-cause death (HR = 5.74, 95% CI = 1.92-16.70, p = 0.001). Severe SDB had a statistically significant impact on the risk of MACEs and mortality in patients undergoing HD. The severity of the 3% ODI via overnight pulse oximetry may be a useful marker as a risk factor for cardiovascular outcomes and mortality in these patients.
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17
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Zheng Z, Soomro QH, Charytan DM. Deep Learning Using Electrocardiograms in Patients on Maintenance Dialysis. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:61-68. [PMID: 36723284 DOI: 10.1053/j.akdh.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Cardiovascular morbidity and mortality occur with an extraordinarily high incidence in the hemodialysis-dependent end-stage kidney disease population. There is a clear need to improve identification of those individuals at the highest risk of cardiovascular complications in order to better target them for preventative therapies. Twelve-lead electrocardiograms are ubiquitous and use inexpensive technology that can be administered with minimal inconvenience to patients and at a minimal burden to care providers. The embedded waveforms encode significant information on the cardiovascular structure and function that might be unlocked and used to identify at-risk individuals with the use of artificial intelligence techniques like deep learning. In this review, we discuss the experience with deep learning-based analysis of electrocardiograms to identify cardiovascular abnormalities or risk and the potential to extend this to the setting of dialysis-dependent end-stage kidney disease.
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Affiliation(s)
- Zhong Zheng
- Nephology Division, Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Qandeel H Soomro
- Nephology Division, Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - David M Charytan
- Nephology Division, Department of Medicine, New York University Grossman School of Medicine, New York, NY.
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18
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Egashira S, Koga M, Toyoda K. Intravenous Thrombolysis for Acute Ischemic Stroke in Patients with End-Stage Renal Disease on Hemodialysis: A Narrative Review. J Cardiovasc Dev Dis 2022; 9:jcdd9120446. [PMID: 36547443 PMCID: PMC9785222 DOI: 10.3390/jcdd9120446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/04/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Acute ischemic stroke (AIS) is a significant and devastating complication in patients with end-stage renal disease on hemodialysis (ESRD/HD). Since one-third of AIS in ESRD/HD patients occurs during or soon after dialysis, patients are more likely to present within the time window when intravenous thrombolysis (IVT) can be performed. IVT may improve prognosis in ESRD/HD patients with AIS. However, ESRD/HD patients have been excluded from large trials and may have been withheld from IVT due to concerns about bleeding complications. To date, there is no clear evidence and firm guidance on the safety and efficacy of IVT in ESRD/HD patients with AIS. This narrative review aimed to evaluate critical scientific data on the benefits and risks of IVT use in patients with ESRD/HD and AIS. MATERIALS AND METHODS We searched the electronic database of PubMed for studies evaluating the relationship between AIS, ESRD/HD, and IVT. Reference sections and additional publications were also searched manually. Studies on AIS in patients with ESRD/HD requiring maintenance dialysis that referred to IVT were included. RESULTS In total, 560 studies were found in the PubMed electronic database during the period covered, of which 10 met the selection criteria. IVT for AIS in ESRD/HD patients could improve neurological outcomes and be safely performed even with the possibility of hemorrhagic complications associated with hypertension. Despite the high complication and mortality rates in ESRD/HD patients with AIS after IVT, the association with IVT was unclear. CONCLUSIONS IVT for AIS in ESRD/HD patients may improve outcomes and should not be withheld based solely on ESRD/HD status.
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Affiliation(s)
| | - Masatoshi Koga
- Correspondence: ; Tel.: +81-6-6170-1070; Fax: +81-6-6170-1348
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19
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Pokorney SD, Chertow GM, Al-Khalidi HR, Gallup D, Dignacco P, Mussina K, Bansal N, Gadegbeku CA, Garcia DA, Garonzik S, Lopes RD, Mahaffey KW, Matsuda K, Middleton JP, Rymer JA, Sands GH, Thadhani R, Thomas KL, Washam JB, Winkelmayer WC, Granger CB. Apixaban for Patients With Atrial Fibrillation on Hemodialysis: A Multicenter Randomized Controlled Trial. Circulation 2022; 146:1735-1745. [PMID: 36335914 DOI: 10.1161/circulationaha.121.054990] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 10/11/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND There are no randomized data evaluating the safety or efficacy of apixaban for stroke prevention in patients with end-stage kidney disease on hemodialysis and with atrial fibrillation (AF). METHODS The RENAL-AF trial (Renal Hemodialysis Patients Allocated Apixaban Versus Warfarin in Atrial Fibrillation) was a prospective, randomized, open-label, blinded-outcome evaluation (PROBE) of apixaban versus warfarin in patients receiving hemodialysis with AF and a CHA2DS2-VASc score ≥2. Patients were randomly assigned 1:1 to 5 mg of apixaban twice daily (2.5 mg twice daily for patients ≥80 years of age, weight ≤60 kg, or both) or dose-adjusted warfarin. The primary outcome was time to major or clinically relevant nonmajor bleeding. Secondary outcomes included stroke, mortality, and apixaban pharmacokinetics. Pharmacokinetic sampling was day 1, day 3, and month 1. RESULTS From January 2017 through January 2019, 154 patients were randomly assigned to apixaban (n=82) or warfarin (n=72). The trial stopped prematurely because of enrollment challenges. Time in therapeutic range (international normalized ratio, 2.0-3.0) for warfarin-treated patients was 44% (interquartile range, 23%-59%). The 1-year rates for major or clinically relevant nonmajor bleeding were 32% and 26% in apixaban and warfarin groups, respectively (hazard ratio, 1.20 [95% CI, 0.63-2.30]), whereas 1-year rates for stroke or systemic embolism were 3.0% and 3.3% in apixaban and warfarin groups, respectively. Death was the most common major event in the apixaban (21 patients [26%]) and warfarin (13 patients [18%]) arms. The pharmacokinetic substudy enrolled the target 50 patients. Median steady-state 12-hour area under the curve was 2475 ng/mL×h (10th to 90th percentiles, 1342-3285) for 5 mg of apixaban twice daily and 1269 ng/mL×h (10th to 90th percentiles, 615-1946) for 2.5 mg of apixaban twice daily. There was substantial overlap between minimum apixaban blood concentration, 12-hour area under the curve, and maximum apixaban blood concentration for patients with and without a major or clinically relevant nonmajor bleeding event. CONCLUSIONS There was inadequate power to draw any conclusion regarding rates of major or clinically relevant nonmajor bleeding comparing apixaban and warfarin in patients with AF and end-stage kidney disease on hemodialysis. Clinically relevant bleeding events were ≈10-fold more frequent than stroke or systemic embolism among this population on anticoagulation, highlighting the need for future randomized studies evaluating the risks versus benefits of anticoagulation among patients with AF and end-stage kidney disease on hemodialysis. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02942407.
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Affiliation(s)
- Sean D Pokorney
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.D.P., H.R.A.-K., D.G., P.D., R.D.L., J.P.M., J.A.R., K.L.T., J.B.W., C.B.G.)
| | | | - Hussein R Al-Khalidi
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.D.P., H.R.A.-K., D.G., P.D., R.D.L., J.P.M., J.A.R., K.L.T., J.B.W., C.B.G.)
| | - Dianne Gallup
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.D.P., H.R.A.-K., D.G., P.D., R.D.L., J.P.M., J.A.R., K.L.T., J.B.W., C.B.G.)
| | - Pat Dignacco
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.D.P., H.R.A.-K., D.G., P.D., R.D.L., J.P.M., J.A.R., K.L.T., J.B.W., C.B.G.)
| | - Kurt Mussina
- Stanford University, Palo Alto, CA (G.M.C., K.W.M., K.M.)
| | - Nisha Bansal
- University of Washington, Seattle (N.B., D.A.G.)
| | | | | | | | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.D.P., H.R.A.-K., D.G., P.D., R.D.L., J.P.M., J.A.R., K.L.T., J.B.W., C.B.G.)
| | | | - Kelly Matsuda
- Stanford University, Palo Alto, CA (G.M.C., K.W.M., K.M.)
- Frenova Renal Research, Waltham, MA (K.M.)
| | - John P Middleton
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.D.P., H.R.A.-K., D.G., P.D., R.D.L., J.P.M., J.A.R., K.L.T., J.B.W., C.B.G.)
| | - Jennifer A Rymer
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.D.P., H.R.A.-K., D.G., P.D., R.D.L., J.P.M., J.A.R., K.L.T., J.B.W., C.B.G.)
| | | | - Ravi Thadhani
- Massachussetts General and Brigham and Women's Hospitals, Boston (R.T.)
| | - Kevin L Thomas
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.D.P., H.R.A.-K., D.G., P.D., R.D.L., J.P.M., J.A.R., K.L.T., J.B.W., C.B.G.)
| | - Jeffrey B Washam
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.D.P., H.R.A.-K., D.G., P.D., R.D.L., J.P.M., J.A.R., K.L.T., J.B.W., C.B.G.)
| | | | - Christopher B Granger
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (S.D.P., H.R.A.-K., D.G., P.D., R.D.L., J.P.M., J.A.R., K.L.T., J.B.W., C.B.G.)
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20
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Hammett C, Badve SV, Kerr PG, Tran HA, Dundon BK, Lo S, Wong A, Joseph JE, Deague J, Perkovic V. Oral Anticoagulant Use in Patients With Atrial Fibrillation and Chronic Kidney Disease: A Review of the Evidence With Recommendations for Australian Clinical Practice. Heart Lung Circ 2022; 31:1604-1611. [PMID: 36336614 DOI: 10.1016/j.hlc.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/10/2022] [Accepted: 09/01/2022] [Indexed: 11/05/2022]
Abstract
Chronic kidney disease is common in patients with atrial fibrillation (AF) and is associated with heightened risks of stroke/systemic embolisation and bleeding. In this review we outline the evidence for AF stroke prevention in kidney disease, identify current knowledge gaps, and give recommendations for anticoagulation at various stages of chronic kidney disease. Overall, anticoagulation is underused. Warfarin use becomes increasingly difficult with advancing kidney disease, with difficulty maintaining international normalised ratio (INR) in therapeutic range, increased risk of intracranial and fatal bleeding compared to non-vitamin K oral anticoagulants (NOACs), and high rates of discontinuation. Similarly, the direct thrombin inhibitor dabigatran is not recommended as it is predominantly renally excreted with consequent increased plasma levels and bleeding risk with advanced kidney disease. The Factor Xa inhibitors apixaban and rivaroxaban have less renal excretion (25-35%), modest increases in plasma levels with advancing kidney disease, and are the preferred first line choice for anticoagulation in moderate kidney disease based on strong evidence from randomised clinical trials (RCTs). In severe kidney disease there is a paucity of RCT data, but extrapolation of the pharmacokinetic and RCT data for moderate kidney disease, and observational studies, support the considered use of dose-adjusted Factor Xa inhibitors unless the bleeding risk is prohibitive. In Australia, apixaban is approved for creatinine clearance down to 25 mL/min, and rivaroxaban down to 15 mL/min. For end-stage kidney disease warfarin is the only agent approved, but we recommend against anticoagulation (except in selected cases) due to high bleeding risk, multiple co-morbidities, and questionable benefit.
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Affiliation(s)
| | - Sunil V Badve
- Department of Nephrology, St George Hospital, and Renal and Metabolic Division, The George Institute for Global Health, Sydney, NSW, Australia
| | - Peter G Kerr
- Department of Nephrology, Monash Medical Centre and Monash University, Melbourne, Vic, Australia
| | - Huyen A Tran
- The Alfred Hospital & Monash University, Melbourne, Vic, Australia
| | - Benjamin K Dundon
- MonashHeart, Monash Health and Victorian Heart Institute, Monash University, Melbourne, Vic, Australia
| | - Sidney Lo
- Liverpool Hospital, SouthWest Sydney Local Health District and University of New South Wales, Sydney, NSW, Australia
| | - Andrew Wong
- Royal Brisbane and Women's Hospital and The University of Queensland, Brisbane, Qld, Australia
| | | | | | - Vlado Perkovic
- Royal North Shore Hospital and The George Institute for Global Health, Sydney, NSW, Australia
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21
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A systematic review of the efficacy and safety of anticoagulants in advanced chronic kidney disease. J Nephrol 2022; 35:2015-2033. [PMID: 36006608 PMCID: PMC9584987 DOI: 10.1007/s40620-022-01413-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/19/2022] [Indexed: 11/17/2022]
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.
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van Ham WB, Cornelissen CM, van Veen TAB. Uremic toxins in chronic kidney disease highlight a fundamental gap in understanding their detrimental effects on cardiac electrophysiology and arrhythmogenesis. Acta Physiol (Oxf) 2022; 236:e13888. [PMID: 36148604 PMCID: PMC9787632 DOI: 10.1111/apha.13888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 09/09/2022] [Accepted: 09/18/2022] [Indexed: 01/29/2023]
Abstract
Chronic kidney disease (CKD) and cardiovascular disease (CVD) have an estimated 700-800 and 523 million cases worldwide, respectively, with CVD being the leading cause of death in CKD patients. The pathophysiological interplay between the heart and kidneys is defined as the cardiorenal syndrome (CRS), in which worsening of kidney function is represented by increased plasma concentrations of uremic toxins (UTs), culminating in dialysis patients. As there is a high incidence of CVD in CKD patients, accompanied by arrhythmias and sudden cardiac death, knowledge on electrophysiological remodeling would be instrumental for understanding the CRS. While the interplay between both organs is clearly of importance in CRS, the involvement of UTs in pro-arrhythmic remodeling is only poorly investigated, especially regarding the mechanistic background. Currently, the clinical approach against potential arrhythmic events is mainly restricted to symptom treatment, stressing the need for fundamental research on UT in relation to electrophysiology. This review addresses the existing knowledge of UTs and cardiac electrophysiology, and the experimental research gap between fundamental research and clinical research of the CRS. Clinically, mainly absorbents like ibuprofen and AST-120 are studied, which show limited safe and efficient usability. Experimental research shows disturbances in cardiac electrical activation and conduction after inducing CKD or exposure to UTs, but are scarcely present or focus solely on already well-investigated UTs. Based on UTs data derived from CKD patient cohort studies, a clinically relevant overview of physiological and pathological UTs concentrations is created. Using this, future experimental research is stimulated to involve electrophysiologically translatable animals, such as rabbits, or in vitro engineered heart tissues.
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Affiliation(s)
- Willem B. van Ham
- Department of Medical Physiology, Division Heart & LungsUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Carlijn M. Cornelissen
- Department of Medical Physiology, Division Heart & LungsUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Toon A. B. van Veen
- Department of Medical Physiology, Division Heart & LungsUniversity Medical Center UtrechtUtrechtThe Netherlands
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23
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Sánchez-González C, Herrero Calvo JA. Nonvalvular atrial fibrillation in patients undergoing chronic hemodialysis. Should dialysis patients with atrial fibrillation receive oral anticoagulation? Nefrologia 2022; 42:633-644. [PMID: 36907719 DOI: 10.1016/j.nefroe.2022.01.013] [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: 01/11/2022] [Accepted: 01/16/2022] [Indexed: 06/18/2023] Open
Abstract
Chronic kidney disease (CKD) is an independent risk factor for presenting atrial fibrillation (AF), which conditions an increased risk already present in CKD of suffering a thromboembolic event. And this risk is even higher in the hemodialysis (HD) population. On the other hand, in CKD patients and even more so in HD patients, the probability of suffering serious bleeding is also higher. Therefore, there is no consensus on whether or not to anticoagulate this population. Taking as a model what is advised for the general population, the most common attitude among nephrologists has been to opt for anticoagulation, even though there is no randomized studies to support it. Classically, anticoagulation has been done with vitamin K antagonists, at high cost for our patients: severe bleeding events, vascular calcification, and progression of nephropathy, among other complications. With the emergence of direct-acting anticoagulants, a hopeful outlook was opened in the field of anticoagulation, as they were postulated as more effective and safer drugs than antivitamin K. However, in clinical practice, this has not been the case. In this paper we review various aspects of AF and its anticoagulant treatment in the HD population.
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Gadde S, Kalluru R, Cherukuri SP, Chikatimalla R, Dasaradhan T, Koneti J. Atrial Fibrillation in Chronic Kidney Disease: An Overview. Cureus 2022; 14:e27753. [PMID: 36106212 PMCID: PMC9445413 DOI: 10.7759/cureus.27753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2022] [Indexed: 11/12/2022] Open
Abstract
Chronic kidney disease (CKD) is a condition that can be caused due to any etiology leading to structural damage to the kidney, which can be measured by a decrease in estimated glomerular filtration rate (eGFR) and the presence of damage biomarkers for more than three months. This article has discussed the causal relationship between atrial fibrillation (AF) and CKD, a few of them being inflammation, renin-angiotensin-aldosterone system (RAAS) activation, anemia, and uremia associated with CKD. This review mentioned the clinical impact of the presence of AF in CKD patients. The presence of AF in CKD patients aggravates the renal dysfunction, which in turn adds to the generation of AF. This article explores the various pharmacological and interventional treatment modalities, including antiarrhythmics, anticoagulants, and cardiac ablation, and their complications, leading to restricted usage in CKD patients.
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25
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Left atrial appendage occlusion should be offered only to select atrial fibrillation patients. Heart Rhythm O2 2022; 3:448-454. [PMID: 36097461 PMCID: PMC9463703 DOI: 10.1016/j.hroo.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 11/21/2022] Open
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26
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Wakasugi M, Yokoseki A, Wada M, Sanpei K, Momotsu T, Sato K, Kawashima H, Nakamura K, Onodera O, Narita I. Stroke incidence and chronic kidney disease: a hospital-based prospective cohort study. Nephrology (Carlton) 2022; 27:577-587. [PMID: 35488413 DOI: 10.1111/nep.14049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/20/2022] [Accepted: 04/25/2022] [Indexed: 11/29/2022]
Abstract
AIM This prospective cohort study aimed to (i) examine stroke incidence and stroke subtypes by chronic kidney disease (CKD) stage, (ii) examine whether CKD patients with or without proteinuria have a high risk of stroke independent of traditional cardiovascular risk factors, and (iii) determine precise estimates of stroke risk by CKD stage while accounting for competing mortality risk. METHODS Participants were 2,023 patients enrolled in the Project in Sado for Total Health between June 2008 and December 2016 (55% men; mean age, 69 years), of whom 52% had CKD (stage 1-2, 10%; G3a, 48%; G3b, 17%; G4-5, 11%; and G5D, 14%). RESULTS During a median follow-up of 5.7 years, 157 participants developed stroke and 448 died without developing stroke. Most stroke cases were ischemic among non-dialysis-dependent CKD participants, but the relative frequency of ischemic stroke was near that of intracerebral hemorrhage among dialysis-dependent CKD participants. After adjustment, stage 1-2 (hazard ratio (HR), 2.97; 95% confidence interval (CI), 1.60 to 5.51) and stage G3-5 participants with proteinuria (HR, 2.50; 95% CI, 1.56 to 4.02), but not stage G3-5 participants without proteinuria (HR, 0.64; 95% CI, 0.38 to 1.08), had a higher stroke risk compared to non-CKD participants. In competing risk analyses, the association was attenuated but remained significant. CONCLUSION Although the distribution of stroke subtypes differed, CKD participants with proteinuria and those with CKD stage 5D had a 2- and 4-times higher risk of stroke, respectively, than that of non-CKD participants, after accounting for competing mortality risk and traditional risk factors. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Minako Wakasugi
- Department of Inter-Organ Communication Research, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Akio Yokoseki
- Department of Inter-Organ Communication Research, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | | | | | | | | | - Hiroyuki Kawashima
- Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Science, Niigata, Japan
| | - Kazutoshi Nakamura
- Division of Preventive Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Osamu Onodera
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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27
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Koplan BA, Winkelmayer WC, Costea AI, Roy-Chaudhury P, Tumlin JA, Kher V, Williamson DE, Pokhariyal S, Charytan DM. Implantable Loop Recorder Monitoring and the Incidence of Previously Unrecognized Atrial Fibrillation in Patients on Hemodialysis. Kidney Int Rep 2022; 7:189-199. [PMID: 35155858 PMCID: PMC8821036 DOI: 10.1016/j.ekir.2021.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 09/17/2021] [Accepted: 10/04/2021] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Atrial fibrillation (AF) is common in patients with kidney failure on hemodialysis (KF-HD). We determined both AF incidence and burden in patients with KF-HD using implantable loop recorder (ILR) monitoring. METHODS Patients with KF-HD were enrolled and received an ILR. In 6 monitoring months, the incidence of AF events lasting ≥6 minutes was captured. Demographic, clinical, and dialysis characteristics were collected, and associations with incident AF were estimated using negative binomial regression models and expressed as incidence rate ratios and 95% CIs. RESULTS We enrolled 66 patients with KF-HD (mean age = 56 years, 70% male); 59 (90%) were without previously diagnosed AF. AF lasting ≥6 minutes was detected in 18 of 59 subjects (31%) without previously diagnosed AF and in 5 of 7 subjects (71%) with a previous AF diagnosis. Among the 23 with detected AF, episodes were present on 16% of patient days. Although 14 of 23 patients (61%) had AF on <5% of monitored days, the average duration of AF episodes was <1 hour in 13 of 23 patients (52%). Among patients with AF ≥6 minutes, 19 of 23 (83%) had a CHA2DS2-VASc score ≥2. When investigating individual HD parameters, higher dialysate calcium (>2.5 vs. 2.5 mEq/l: incidence rate ratio = 0.62; 95% CI, 0.48-0.80) was associated with lower AF risk whereas higher dialysate bicarbonate concentrations (>35 vs. 35 mEq/l: incidence rate ratio = 3.18; 95% CI, 1.13-8.94) were associated with higher AF risk. CONCLUSION New AF was detected in approximately one-third of patients with KF-HD. AF affects a substantial proportion of patient days and may be an underappreciated cause of stroke in KF-HD.
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Affiliation(s)
- Bruce A. Koplan
- Cardiology Division, Brigham & Women’s Hospital, Boston, Massachusetts, USA
| | | | - Alexandru I. Costea
- Cardiology Division, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - Prabir Roy-Chaudhury
- Department of Medicine, University of North Carolina Kidney Center, Chapel Hill, North Carolina, USA
- Department of Medicine, WG (Bill) Hefner VA Medical Center, Salisbury, North Carolina, USA
| | - James A. Tumlin
- Georgia Nephrology Clinical Research Institute, Atlanta, Georgia, USA
| | - Vijay Kher
- Medanta Kidney & Urology Institute, Medanta, The Medicity, Gurugram, India
| | | | - Saurabh Pokhariyal
- Division of Nephrology and Renal Transplantation, Manipal Hospitals, Dwarka, New Delhi, India
| | - David M. Charytan
- Nephrology Division, NYU Grossman School of Medicine, New York, New York, USA
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Belmouaz M, Goussard G, Joly F, Grand F, Sibille A, Ecotiere L, Desport E, Bauwens M, Thierry A, Bridoux F. Comparison of the injection of low-molecular weight heparin in the arterial vs. venous blood line for preventing extracorporeal circuit clotting during hemodialysis. Hemodial Int 2022; 26:314-322. [PMID: 35014175 DOI: 10.1111/hdi.13004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 12/01/2022]
Abstract
Low-molecular weight heparins (LMWH) are widely used for preventing clotting during hemodialysis (HD). Although injection in the venous blood line is recommended to avoid initial loss of LMWH through the dialyzer, LMWH is still frequently administered in the arterial blood line at the start of dialysis. This study aimed to compare the safety and efficacy of the same enoxaparin dose administered through the venous blood line or arterial blood line. We also evaluated antifactor Xa (aXa) activity according to the injection route and dialysis modalities: high-flux (HF) HD, medium cut-off (MCO) HD, and online hemodiafiltration (OL-HDF). Forty-three patients were studied over 18 consecutive dialysis sessions using a fixed enoxaparin dose (20 or 40 mg), first administered through the arterial blood line bolus and then through the venous blood line for another 18 sessions. Compared to arterial blood line administration, venous blood line bolus resulted in a significant increase in median post-dialysis aXa activity: 0.16 (0.1-0.6) IU/ml versus 0.31 (0.1-1.3) IU/ml, respectively, p = 0.006. After arterial blood line bolus of 40 mg enoxaparin, median post-dialysis aXa activity was significantly lower with OL-HDF compared to HF-HD: 0.14 (0.1-0.35) versus 0.32 (0.15-0.49), p = 0.02. A trend for lower clotting within lines and bubble trap using venous blood line bolus was observed. In conclusion, venous blood line enoxaparin injection is safe in OL-HDF patients. However, in HF-HD and MCO-HD, venous blood line injection of 40 mg enoxaparin may increase overdosing risk. Thus, aXa activity should be monitored in HF-HD and MCO-HD patients at risk of bleeding and/or on vitamin K antagonists and careful surveillance is required when administering a 40 mg enoxaparin dose through the venous blood line route.
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Affiliation(s)
- Mohamed Belmouaz
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Guillaume Goussard
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Florent Joly
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Francois Grand
- Laboratory of Hematology, Poitiers University Hospital, Poitiers, France
| | - Audrey Sibille
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Laure Ecotiere
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Estelle Desport
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Marc Bauwens
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Antoine Thierry
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | - Frank Bridoux
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
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29
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Akbar MR, Febrianora M, Iqbal M. Warfarin Usage in Patients with Atrial Fibrillation Undergoing Hemodialysis in Indonesian Population. Curr Probl Cardiol 2022; 48:101104. [PMID: 35041867 DOI: 10.1016/j.cpcardiol.2022.101104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/03/2022] [Indexed: 11/16/2022]
Abstract
The data about the efficacy and safety of warfarin usage in atrial fibrillation (AF) in hemodialysis patients is still limited, especially in the Asia population. The population of this study was end-stage renal disease patients with AF who underwent hemodialysis. The design of the study was a retrospective observational cohort that collected the patient data from 2016 to 2019. The Cox regression model was applied to assess the effect of warfarin on the outcomes. We conducted a survival analysis by comparing Kaplan-Meier curves using the log-rank test. We also measured the time in therapeutic range as a quality indicator of warfarin usage. Among 444 hemodialysis patients, 126 patients with AF matched the inclusion criteria, 88 patients completely followed up. Half patients used warfarin. The mean age was 52.2 ± 12.97 years, the mean follow-up duration was 11 ± 10 months. We observed all-cause death in 86.4% of patients, ischemic stroke in 10.2%, and hemorrhagic stroke in 2.3% of patients. There were no significant differences in all-cause death, ischemic stroke, and hemorrhagic stroke. Warfarin use was not associated with a lower rate for death (HR 0.782; 95% CI, 0.494-1.237, P = 0.293) or ischemic stroke (HR 0.435; 95% CI, 0.103-1.846, P = 0.259) or hemorrhagic stroke (HR 0.564; 95% CI, 0.034-9.386, P = 0.689). None of the patients reach the time in the therapeutic range >65%. Our findings suggest that warfarin has no association with mortality, ischemic stroke, and hemorrhagic stroke events rate in atrial fibrillation patients who underwent hemodialysis in the Indonesian population.
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Affiliation(s)
- Mohammad Rizki Akbar
- Department of Cardiology and Vascular Medicine, Hasan Sadikin General Hospital - Universitas Padjadjaran, Bandung, Indonesia.
| | - Mega Febrianora
- Department of Cardiology and Vascular Medicine, Hasan Sadikin General Hospital - Universitas Padjadjaran, Bandung, Indonesia
| | - Mohammad Iqbal
- Department of Cardiology and Vascular Medicine, Hasan Sadikin General Hospital - Universitas Padjadjaran, Bandung, Indonesia
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Chandrasegaram A, Peters CD. The use of non-vitamin K oral anticoagulants in dialysis patients-A systematic review. Semin Dial 2022; 35:463-480. [PMID: 35623902 PMCID: PMC9796794 DOI: 10.1111/sdi.13098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 04/11/2022] [Accepted: 05/05/2022] [Indexed: 01/07/2023]
Abstract
Non-vitamin K oral anticoagulants (NOACs) are used for prevention of thromboembolic events, but their use in dialysis patients is debatable. This study investigated the available evidence for the use of NOACs in dialysis patients. Online databases were systematically searched for eligible studies including pharmacokinetic (PK) studies, cohort studies, and randomized control trials (RCTs) comparing NOAC with vitamin K antagonist (VKA) or no anticoagulant treatment. Newcastle Ottawa Scale and Cochrane Risk of bias tool were used for quality assessment. Twenty studies were identified (nine PK studies, two RCTs, and nine cohort studies). Most of the studies investigated apixaban or rivaroxaban. In dialysis patients, less accumulation was reported with apixaban and rivaroxaban compared to dabigatran and edoxaban. PK studies indicate that high dose apixaban or rivaroxaban should be avoided. The two RCTs (rivaroxaban/apixaban vs. VKA) were small and underpowered regarding stroke and bleeding outcomes. Most cohort studies found apixaban superior to VKA, whereas comparison of rivaroxaban with VKA yielded conflicting results. Cohort studies comparing apixaban high dose (5 mg) with low dose (2.5 mg) twice daily suggest a lower risk of stroke with high dose but also a higher risk of bleeding with high dose. Apixaban versus no anticoagulation was compared in one cohort study and did not lower the risk of stroke compared with non-treated regardless of apixaban dosage. Widespread use of NOACs in dialysis patients is limited by adequately sized RCTs. Available evidence suggests a potential for use of apixaban and rivaroxaban in reduced dose.
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Affiliation(s)
| | - Christian Daugaard Peters
- Department of Renal MedicineAarhus University HospitalAarhus
- Department of Clinical MedicineAarhus UniversityAarhus
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31
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Stephen E, Pawar P, Kota A, Sen I, Al Rawahi B, Varughese S, Khan S. Chronic kidney disease and anticoagulation - Quick overview and practical guide. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2022. [DOI: 10.4103/ijves.ijves_90_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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32
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Fibrilación auricular no valvular en pacientes en hemodiálisis crónica. ¿Debemos anticoagular? Nefrologia 2022. [DOI: 10.1016/j.nefro.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Chang YK, Fan HC, Hsu CC, Lim PS. The association between EKG abnormalities and the development of microalbuminuria in type 2 diabetes. Medicine (Baltimore) 2021; 100:e28018. [PMID: 34941042 PMCID: PMC8702232 DOI: 10.1097/md.0000000000028018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 11/11/2021] [Indexed: 01/05/2023] Open
Abstract
Microalbuminuria is associated with both with chronic kidney disease and various cardiovascular abnormalities. Given the common use of electrocardiograms (EKGs) in diagnosing cardiovascular dysfunction, this study is analyzing the relationship between EKG abnormalities and diabetic nephropathy in type 2 diabetes mellitus (DM) patients. The enrollments of this study were from the 10-year follow-up data (2003-2012) of the Diabetes Management through an Integrated Delivery System project. All study subjects underwent at least 1 EKG measurement. The urinary microalbuminuria was recorded annually. The logistic regression model was used to evaluate the association between EKG abnormalities and the occurrence of diabetic nephropathy in type 2 DM patients. The total of 1189 patients with type 2 DM are included in this study and a total of 552 patients had microalbuminuria during a 10-year follow-up. A significantly higher odds ratio of microalbuminuria occurrence (4.85) was found in the patients with premature supraventricular contraction or tachycardia compared to those without EKG abnormalities. The odds ratios of microalbuminuria occurrence were 1.00, 2.43, 2.64, and 2.98, respectively, for patients with insulin resistance in the Q (quartile) 1(as the reference), Q2, Q3, and Q4, respectively. Our findings can serve as a reference for the association between EKG abnormalities and the development of microalbuminuria in type 2 diabetes.
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Affiliation(s)
- Yu-Kang Chang
- Department of Medical Research, Tungs’ Taichung MetroHarbor Hospital, Taichung, Taiwan
- Department of Nursing, Jenteh Junior College of Medicine, Nursing and Management, Miaoli, Taiwan
| | - Hueng-Chuen Fan
- Department of Medical Research, Tungs’ Taichung MetroHarbor Hospital, Taichung, Taiwan
- Department of Pediatrics, Tungs’ Taichung MetroHarbor Hospital, Taichung, Taiwan
- Department of Rehabilitation, Jenteh Junior College of Medicine, Nursing and Management, Miaoli, Taiwan
| | - Chih-Cheng Hsu
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan
- Department of Health Services Administration, China Medical University, Taichung, Taiwan
- Department of Family Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan
| | - Paik-Seong Lim
- Department of Rehabilitation, Jenteh Junior College of Medicine, Nursing and Management, Miaoli, Taiwan
- Division of Renal Medicine, Tungs’ Taichung MetroHarbor Hospital, Taichung, Taiwan
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Königsbrügge O, Meisel H, Beyer A, Schmaldienst S, Klauser-Braun R, Lorenz M, Auinger M, Kletzmayr J, Hecking M, Winkelmayer WC, Lang I, Pabinger I, Säemann M, Ay C. Anticoagulation use and the risk of stroke and major bleeding in patients on hemodialysis: From the VIVALDI, a population-based prospective cohort study. J Thromb Haemost 2021; 19:2984-2996. [PMID: 34418291 DOI: 10.1111/jth.15508] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/10/2021] [Accepted: 08/20/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Evidence supporting the use of anticoagulation for the prevention of stroke and thromboembolism in patients with kidney failure on hemodialysis (HD) and atrial fibrillation (AF) is limited. We prospectively assessed the incidences of stroke and major bleeding, as well as anticoagulation strategies in patients on HD with AF. METHODS We recruited 625 prevalent HD patients into a population-based observational cohort study. The primary prospective outcomes were thromboembolic events (stroke, transient ischemic attack, systemic embolism) and major bleeding. Secondary outcomes included a composite of thromboembolic events, major bleeding, and cardiovascular death to determine net clinical harm. RESULTS A total of 238 patients (38.1%) had AF, 165 (26.4%) already at baseline and 73 (15.9%) developed AF during a median follow up of 870 days. Forty (6.4%) thromboembolic events and 89 (14.2%) major bleedings occurred. Overall, 256 patients died (41.0%). In AF patients, use of vitamin K antagonists (VKAs) in 61 patients (25.6%) was not significantly associated with reduced risk of the primary thromboembolic outcome (subdistribution hazard ratio [SHR] 1.41 adjusted for age, sex, congestive heart failure, hypertension, stroke/transient ischemic attack/thromboembolism, vascular disease, and diabetes history score and antiplatelet co-medication (95% CI, 0.49-4.07), but with increased risk of major bleeding (SHR: 2.28; 95% CI, 1.09-4.79) compared with AF patients without anticoagulation (N = 139, 58.4%). Use of VKAs was associated with net clinical harm (adjusted SHR: 2.07; 95% CI, 1.25-3.42). CONCLUSIONS Although the nonrandomized nature of the study is prone to bias, anticoagulation with VKAs was not associated with decreased thromboembolic risk, but rather with increased risk of major bleeding and may be net harmful to patients with AF on HD.
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Affiliation(s)
- Oliver Königsbrügge
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Hannah Meisel
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Aljoscha Beyer
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | | | | | | | - Martin Auinger
- Department of Medicine III, Clinic Hietzing, Vienna, Austria
| | - Josef Kletzmayr
- Department of Medicine III, Clinic Donaustadt, Vienna, Austria
| | - Manfred Hecking
- Clinical Division of Nephrology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Wolfgang C Winkelmayer
- Section of Nephrology, Department of Medicine, Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, USA
| | - Irene Lang
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Marcus Säemann
- Department of Medicine VI, Clinic Ottakring, Vienna, Austria
| | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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Wang Z, Xiang Q, Hu K, Zhang X, Xie Q, Liu Z, Cui Y. Comparison of the Safety and Efficacy of Direct Oral Anticoagulants and Warfarin in Atrial Fibrillation or Venous Thromboembolism in Patients with Renal Impairment: Systematic Review, Meta-Analysis and Network Meta-Analysis. Am J Cardiovasc Drugs 2021; 21:643-657. [PMID: 33817758 DOI: 10.1007/s40256-021-00469-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Due to the high risk of ischemic and arterial or venous bleeding events in atrial fibrillation (AF) or venous thromboembolism (VTE) patients with renal impairment (RI), selection of appropriate anticoagulant regimen is important. Therefore, we systematically reviewed and compared the safety and effects of oral anticoagulants in AF and VTE patients with RI. METHODS Eligible articles were identified through a literature search in PubMed, Embase, ClinicalTrials.gov, and the Cochrane Library for studies published between January 2008 and November 2020. Network meta-analysis was conducted with STATA 14.0 to analyze the effects and safety of each drug with regard to different levels of renal function. RESULTS 15 studies including 82,931 patients (76,957 with AF and 5974 with VTE) were analyzed. Compared with those of warfarin, the risk ratios of effect and safety outcomes of apixaban were 0.70 (95% confidence interval [CI] 0.60-0.82) and 0.56 (95% CI 0.42-0.76) in AF patients and 0.33 (95% CI 0.19-0.59) and 0.95 (95% CI 0.68-1.34) in VTE patients. Apixaban had the first or second highest probability of being ranked first with respect to surface under the cumulative ranking curve (SUCRA) scores in the prevention of major bleeding events, while in the prevention of ischemic events, rivaroxaban showed a higher SUCRA score (0.78-0.92) in mild RI patients and dabigatran showed a higher SUCRA value (0.90-0.99) in moderate RI patients. CONCLUSIONS AND RELEVANCE In the systematic review and meta-analysis, for AF or VTE patients with RI, direct oral anticoagulants performed comparably to or better than warfarin with regard to safety and effects. The network meta-analysis indicated that for patients with mild RI, apixaban might be safer for patients with a lower risk of ischemic events, while rivaroxaban might be suitable for patients with a lower risk of bleeding events. For patients with moderate RI, apixaban could reduce the risk of ischemic events without increasing the risk of bleeding events. For AF patients with severe RI, apixaban, rivaroxaban, and warfarin showed a similar effect. These results might provide suggestions for clinical arterial and venous thrombosis prevention.
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Affiliation(s)
- Zhe Wang
- Department of Pharmacy, Peking University First Hospital, No. 6 Dahongluohang Street, Xicheng District, Beijing, 100034, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Peking University Health Science Center, Beijing, China
| | - Qian Xiang
- Department of Pharmacy, Peking University First Hospital, No. 6 Dahongluohang Street, Xicheng District, Beijing, 100034, China.
| | - Kun Hu
- Department of Pharmacy, Peking University First Hospital, No. 6 Dahongluohang Street, Xicheng District, Beijing, 100034, China
| | - Xiaodan Zhang
- Department of Pharmacy, Peking University First Hospital, No. 6 Dahongluohang Street, Xicheng District, Beijing, 100034, China
| | - Qiufen Xie
- Department of Pharmacy, Peking University First Hospital, No. 6 Dahongluohang Street, Xicheng District, Beijing, 100034, China
| | - Zhiyan Liu
- Department of Pharmacy, Peking University First Hospital, No. 6 Dahongluohang Street, Xicheng District, Beijing, 100034, China
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, No. 6 Dahongluohang Street, Xicheng District, Beijing, 100034, China.
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Peking University Health Science Center, Beijing, China.
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Munir MB, Khan MZ, Darden D, Nishimura M, Vanam S, Pasupula DK, Asad ZUA, Bhagat A, Zahid S, Osman M, Balla S, Han FT, Reeves R, Hsu JC. Association of chronic kidney disease and end-stage renal disease with procedural complications and in-hospital outcomes from left atrial appendage occlusion device implantation in patients with atrial fibrillation: Insights from the national inpatient sample of 36,065 procedures. Heart Rhythm O2 2021; 2:472-479. [PMID: 34667962 PMCID: PMC8505197 DOI: 10.1016/j.hroo.2021.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background Left atrial appendage occlusion (LAAO) has emerged as an alternative strategy to oral anticoagulation for mitigating ischemic stroke risk in selected patients with atrial fibrillation (AF), but safety data in patients with significant kidney disease are limited. Objective To determine the association of chronic kidney disease (CKD) and end-stage renal disease (ESRD) with procedural complications and in-hospital outcomes after LAAO in AF patients. Methods Data were extracted from National Inpatient Sample for calendar years 2015–2018. Watchman implantations were identified on the basis of International Classification of Diseases, 9th and 10th Revision, Clinical Modification codes of 37.90 and 02L73DK. The outcomes assessed in our study included complications, inpatient mortality, and resource utilization with LAAO. Results A total of 36,065 Watchman recipients were included in the final analysis. CKD (9.8%, n = 3545) and ESRD (3%, n = 1155) were associated with a higher prevalence of major complications and mortality in crude analysis compared to no CKD. After multivariate adjustment for potential confounders, CKD was associated with length of stay (LOS) >1 day (adjusted odds ratio [aOR] 1.355; 95% confidence interval [CI] 1.234–1.488), median cost >$24,663 (aOR 1.267; 95% CI 1.176–1.365), and acute kidney injury (aOR 4.134; 95% CI 3.536–4.833), while ESRD was associated with in-patient mortality (aOR 7.156; 95% CI 3.294–15.544). Conclusion The prevalence of CKD and ESRD was approximately 13% in AF patients undergoing Watchman LAAO implantations. CKD was independently associated with prolonged LOS, higher hospitalization costs, and acute kidney injury, while ESRD was independently associated with in-patient mortality.
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Affiliation(s)
- Muhammad Bilal Munir
- Section of Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla, California
| | - Muhammad Zia Khan
- Division of Cardiovascular Medicine, West Virginia University Heart & Vascular Institute, Morgantown, West Virginia
| | - Douglas Darden
- Section of Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla, California
| | - Marin Nishimura
- Section of Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla, California
| | - Sai Vanam
- Section of Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla, California
| | | | - Zain Ul Abideen Asad
- Division of Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Abhishek Bhagat
- Division of Cardiology, University of Arizona College of Medicine, Phoenix, Arizona
| | - Salman Zahid
- Department of Medicine, Rochester General Hospital, Rochester, New York
| | - Mohammed Osman
- Division of Cardiovascular Medicine, West Virginia University Heart & Vascular Institute, Morgantown, West Virginia
| | - Sudarshan Balla
- Division of Cardiovascular Medicine, West Virginia University Heart & Vascular Institute, Morgantown, West Virginia
| | - Frederick T. Han
- Section of Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla, California
| | - Ryan Reeves
- Section of Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla, California
| | - Jonathan C. Hsu
- Section of Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla, California
- Address reprint requests and correspondence: Dr Jonathan C. Hsu, Associate Professor of Medicine, University of California San Diego, 9452 Medical Center Dr, MC7411, La Jolla, CA 92037.
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Kotta PA, Elango M, Papalois V. Preoperative Cardiovascular Assessment of the Renal Transplant Recipient: A Narrative Review. J Clin Med 2021; 10:2525. [PMID: 34200235 PMCID: PMC8201125 DOI: 10.3390/jcm10112525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/27/2021] [Accepted: 05/29/2021] [Indexed: 12/23/2022] Open
Abstract
Patients with end-stage kidney disease (ESKD) have a high prevalence of cardiovascular disease; it is the leading cause of death in these patients and the optimisation of their cardiovascular health may improve their post-transplant outcomes. Patients awaiting renal transplant often spend significant amounts of time on the waiting list allowing for the assessment and optimisation of their cardiovascular system. Coronary artery disease (CAD) is commonly seen in these patients and we explore the possible functional and anatomical investigations that can help assess and manage CAD in renal transplant candidates. We also discuss other aspects of cardiovascular assessment and management including arrhythmias, impaired ventricular function, valvular disease, lifestyle and pulmonary arterial hypertension. We hope that this review can form a basis for centres hoping to implement an enhanced recovery after surgery (ERAS) protocol for renal transplantation.
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Affiliation(s)
| | - Madhivanan Elango
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK;
| | - Vassilios Papalois
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK;
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Van den Bosch I, Bouillon T, Verhamme P, Vanassche T, Jacquemin M, Coemans M, Kuypers D, Meijers B. Apixaban in patients on haemodialysis: a single-dose pharmacokinetics study. Nephrol Dial Transplant 2021; 36:884-889. [PMID: 33351142 DOI: 10.1093/ndt/gfaa351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Apixaban, a direct oral anticoagulant inhibiting factor Xa, has been proven to reduce the risk of atrial fibrillation-related stroke and thromboembolism in patients with mild to moderate renal insufficiency. Patients on renal replacement therapy, however, were excluded from randomized controlled trials. Therefore, uncertainty remains concerning benefits, dosing and timing of intake in haemodialysis population. METHODS We conducted a Phase II pharmacokinetics study in which 24 patients on maintenance haemodialysis were given a single dose (2.5 mg or 5 mg) of apixaban, either 30 min before or immediately after dialysis on the mid-week dialysis day. RESULTS Apixaban 5 mg resulted in higher area under the curve (AUC0-48) in comparison with 2.5 mg, although significance could only be reached for dosing pre-dialysis (2.5 mg versus 5 mg, P = 0.008). In line, peak concentrations (Cmax) after dosing pre-dialysis were significantly higher in the 5 mg than in the 2.5 mg groups (P = 0.02). In addition, dialysis resulted in significant reduction of drug exposure. AUC0-48 pre-dialysis were on average 48% (2.5 mg) and 26% (5 mg) lower than the AUC0-48 post-dialysis, in line with Cmax. As a result, a dose of 2.5 mg post-dialysis and a dose of 5 mg pre-dialysis resulted in similar AUC0-48. In contrast, significant differences were found between the 5 mg group post-dialysis and the 2.5 mg group pre-dialysis (P = 0.02). CONCLUSIONS Our data suggest that exposure to apixaban in patients on maintenance haemodialysis is dependent not only on drug dose but also on timing of intake relative to the haemodialysis procedure.
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Affiliation(s)
| | - Thomas Bouillon
- Department of Biomedical Sciences, University of Leuven, Leuven, Belgium.,Department of Pharmacometrics, University of Leuven, Leuven, Belgium
| | - Peter Verhamme
- Center for Molecular and Vascular Biology, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, University Hospitals Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Center for Molecular and Vascular Biology, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, University Hospitals Leuven, Leuven, Belgium
| | - Marc Jacquemin
- Center for Molecular and Vascular Biology, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium.,Department of Haemostasis in Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Maarten Coemans
- Leuven Biostatistics and Statistical bioinformatics Center, Leuven, Belgium
| | - Dirk Kuypers
- Division of Nephrology, UZ Leuven, Leuven, Belgium.,Laboratory of Nephrology, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Björn Meijers
- Division of Nephrology, UZ Leuven, Leuven, Belgium.,Laboratory of Nephrology, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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Su X, Yan B, Wang L, Lv J, Cheng H, Chen Y. Oral Anticoagulant Agents in Patients With Atrial Fibrillation and CKD: A Systematic Review and Pairwise Network Meta-analysis. Am J Kidney Dis 2021; 78:678-689.e1. [PMID: 33872690 DOI: 10.1053/j.ajkd.2021.02.328] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 02/02/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To evaluate the relative efficacy and safety of different oral anticoagulant agents (OACs) for patients with atrial fibrillation (AF) and chronic kidney disease (CKD). STUDY DESIGN Systematic review and pairwise and Bayesian network meta-analysis. SETTING & STUDY POPULATIONS Adult patients with AF and CKD stages 3-5D who received OACs. SELECTION CRITERIA FOR STUDIES Randomized controlled trials (RCTs) and observational studies that reported the efficacy and safety outcomes of subgroups with a glomerular filtration rate (GFR)<60mL/min. DATA EXTRACTION Two reviewers independently abstracted data, assessed study quality, and rated the strength of evidence (SOE). ANALYTICAL APPROACH Random-effects models using restricted maximum-likelihood methods were fit for the pairwise meta-analyses as well as a network meta-analysis within a Bayesian framework. RESULTS Pairwise meta-analysis including 8 RCTs and 46 observational studies showed that direct OACs (DOACs) were superior to warfarin in preventing thromboembolic events (hazard ratio [HR], 0.86 [95% CI, 0.78-0.95]), without heterogeneity (I2=10.5%), and in reducing the risk of bleeding events (HR, 0.81 [95% CI, 0.66-0.99]), with substantial heterogeneity (I2=69.8%), in patients with AF and a GFR of 15-60mL/min. Bayesian network meta-analysis including 8 RCTs showed that dose-adjusted apixaban and a 15-mg dose of edoxaban were superior to the other OAC regimens in reducing bleeding events. Dose-adjusted apixaban was more effective than edoxaban in preventing thromboembolic events for patients with AF and GFR in the range of 25-50 or 30-50mL/min. In dialysis recipients with AF, the use of OACs increased the risk of bleeding events by 28% (HR, 1.28 [95% CI, 1.03-1.60]) without significant beneficial effects versus not using anticoagulants. LIMITATIONS Low SOE and heterogeneity in most comparisons. CONCLUSIONS This study suggests that DOACs are superior to warfarin for the prevention of thromboembolic events and reduction in bleeding risk in patients with AF and mild to moderate kidney disease. However, the low SOE limits the conclusions that can be drawn about the preferred DOAC. Notably, the use of OACs may increase bleeding risk without significant benefits in dialysis recipients with AF. REGISTRATION Registered at PROSPERO with identification number CRD42018090896.
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Affiliation(s)
- Xiaole Su
- Division of Nephrology, Beijing Anzhen Hospital, Capital Medical University; Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, China
| | - Bingjuan Yan
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, China
| | - Lihua Wang
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, China
| | - Jicheng Lv
- Division of Nephrology, Peking University First Hospital, Peking University Institute of Nephrology, Beijing
| | - Hong Cheng
- Division of Nephrology, Beijing Anzhen Hospital, Capital Medical University
| | - Yipu Chen
- Division of Nephrology, Beijing Anzhen Hospital, Capital Medical University.
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Effectiveness and safety of rivaroxaban versus warfarin in Taiwanese patients with end-stage renal disease and nonvalvular atrial fibrillation: A real-world nationwide cohort study. PLoS One 2021; 16:e0249940. [PMID: 33831130 PMCID: PMC8031437 DOI: 10.1371/journal.pone.0249940] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 03/27/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The optimal anticoagulant for end-stage renal disease patients for stroke prophylaxis is unknown. The efficacy and safety of warfarin in this population are debatable. In addition, real-world evidence of direct oral anticoagulants in patients with end-stage renal disease is limited. The aim of this study was to evaluate the clinical outcomes of rivaroxaban compared with warfarin in Taiwanese patients with end-stage renal disease with nonvalvular atrial fibrillation in a real-world setting. METHODS AND RESULTS This was a retrospective population-based cohort study conducted using Taiwan's National Health Insurance Research Database. Patients with nonvalvular atrial fibrillation and end-stage renal disease who started on rivaroxaban or warfarin between February 2013 and September 2017 were eligible to participate in the study. The inverse probability of treatment weighting approach was used to balance baseline characteristics. Bleeding and thromboembolic outcomes were compared using competing risk analyses. The study population consisted of 3358 patients (173 and 3185 patients on rivaroxaban and warfarin, respectively). In the rivaroxaban group, 50.8%, 38.7%, and 10.4% of the patients received 10, 15, and 20 mg of the drug, respectively. The cumulative incidence of major bleeding was similar between the two groups; however, the gastrointestinal bleeding rate was lower in the rivaroxaban group (adjusted subdistribution hazard ratio [SHR]: 0.56, 95% confidence interval [CI]: 0.34-0.91) than in the warfarin group. Furthermore, the composite risk of ischemic stroke or systemic embolism was significantly lower in the rivaroxaban group (adjusted SHR: 0.36, 95% CI: 0.17-0.79). Similar findings were observed for patients who received 10 mg of rivaroxaban. CONCLUSIONS In Taiwanese patients with end-stage renal disease and nonvalvular atrial fibrillation, rivaroxaban may be associated with a similar risk of major bleeding but a lower risk of thromboembolism compared with warfarin. The potential benefit of 10 mg of rivaroxaban in this population requires further investigation.
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Vio R, Proietti R, Rigato M, Calò LA. Clinical Evidence for the Choice of the Direct Oral Anticoagulant in Patients with Atrial Fibrillation According to Creatinine Clearance. Pharmaceuticals (Basel) 2021; 14:ph14030279. [PMID: 33808739 PMCID: PMC8003529 DOI: 10.3390/ph14030279] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/14/2021] [Accepted: 03/16/2021] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Riccardo Vio
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Riccardo Proietti
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Matteo Rigato
- Department of Medicine, Nephrology, Dialysis and Transplantation Unit, University of Padova, 35128 Padova, Italy
| | - Lorenzo Arcangelo Calò
- Department of Medicine, Nephrology, Dialysis and Transplantation Unit, University of Padova, 35128 Padova, Italy
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Chantrarat T, Krittayaphong R. The Clinical Outcomes of Different eGFR Strata and Time in Therapeutic Range in Atrial Fibrillation Patients with Chronic Kidney Disease: A Nationwide Cohort Study. Curr Probl Cardiol 2021; 46:100838. [PMID: 33992427 DOI: 10.1016/j.cpcardiol.2021.100838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 03/06/2021] [Indexed: 10/21/2022]
Abstract
Chronic kidney disease (CKD) is associated with increased risk of stroke, major bleeding, morbidity and overall mortality in atrial fibrillation patients. The aim of this study is to demonstrate the effect of different eGFR strata and the TTR on clinical outcomes in AF patients with CKD.NVAF patients were consecutively enrolled from hospitals across Thailand. eGFR were categorized into three different eGFR categories; eGFR >60, 30-59 and <30 mL/min/1.73 m2. TTR values were also categorized into TTR >75%, TTR 60-75 and TTR <60%. We identified 1,739 patients who received warfarin. Among patients who acquired TTR<60, those with eGFR <30 ml/min/1.73 m2 demonstrated the highest stroke/SSE rate of 8.5% (P<0.001). Patients with eGFR <30 ml/min/1.73 m2, in addition to the presence of TTR<60, were at the highest risk to developing major bleeding with the rate of 17.9% (p <0.001). However, intracranial hemorrhage (ICH) appeared towards increasing rate with the combination of eGFR at even <60 ml/min/1.73 m2 and TTR <60. Death was also considerably high with the rate of 17.9% in patients with the combination of TTR <60 and eGFR <30 ml/min/1.73 m2. Severe CKD resulted in higher risks of stroke/SSE, major bleeding and death in patients with low TTR. Patients with TTR >60, especially TTR >75%, is associated with reduced risk of stroke/SSE, major bleeding and death irrespective of eGFR level. The combination of low TTR <60 and eGFR level less than 60 ml/min/1.73 m2 substantially increased risks of all cardiovascular outcomes.
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Affiliation(s)
- Thoranis Chantrarat
- Division of Cardiology, Department of Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand.
| | - Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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43
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Schlieper G. Cardiovascular evaluation in advanced chronic kidney disease. Herz 2021; 46:212-216. [PMID: 33651163 DOI: 10.1007/s00059-021-05028-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2021] [Indexed: 11/28/2022]
Abstract
Patients with chronic kidney disease (CKD) display an increased cardiovascular comorbidity, which is often underdiagnosed. Thus, effective cardiovascular diagnostic testing is of particular importance for this group of patients. Data from prospective randomized trials with cardiovascular diagnostic testing in CKD patients and improved outcome are limited. Diagnostic stress testing for CKD patients requires special consideration. Guidelines recommend cardiovascular diagnostic testing for patients undergoing an evaluation before transplantation.
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Affiliation(s)
- Georg Schlieper
- Center for Nephrology, Hypertension, and Metabolic Diseases, Heidering 31, 30625, Hannover, Germany.
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Abstract
Incidence and prevalence of atrial fibrillation (AF) and chronic kidney disease are increasing, and the two conditions commonly coexist. Renal impairment further increases the risk of ischemic stroke and systemic thromboembolism in patients with AF but also paradoxically predisposes to bleeding. Renal function should be monitored closely in patients with AF requiring oral anticoagulation therapy, particularly those receiving direct oral anticoagulants. Vitamin K antagonists can be used as part of a dose-adjusted anticoagulation regimen in patients with mild to moderate renal dysfunction. Dialysis-dependent patients taking vitamin K antagonists are at increased risk of sustaining major hemorrhage.
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Affiliation(s)
- Maria Stefil
- Department of Cardiology, Royal Liverpool Hospital, Prescot Street, Liverpool, L7 8XP, UK; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK
| | - Katarzyna Nabrdalik
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK; Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK; Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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45
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De Vriese AS, Heine G. Anticoagulation Management In Hemodialysis Patients With Atrial Fibrillation: Evidence And Opinion. Nephrol Dial Transplant 2021; 37:2072-2079. [PMID: 33647941 DOI: 10.1093/ndt/gfab060] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Indexed: 01/09/2023] Open
Abstract
In the absence of robust evidence to guide clinical decision making, the optimal approach to prevent stroke and systemic embolism in hemodialysis patients with atrial fibrillation (AF) remains moot. In this position paper, studies on oral anticoagulation in hemodialysis patients with AF are highlighted, followed by an evidence-based conclusion, a critical analysis to identify sources of bias, and practical opinion-based suggestions on how to manage anticoagulation in this specific population. It remains unclear whether AF is a true risk factor for embolic stroke in hemodialysis. The currently employed cutoff values for the CHA2DS2-VASc score do not adequately discriminate dialysis patients deriving a net benefit from those suffering a net harm from oral anticoagulation. Anticoagulation initiation should probably be more restrictive than currently advocated by official guidelines. Recent evidence reveals that the superior benefit-risk profile of direct oral anticoagulants (DOAC) versus vitamin K antagonists (VKA) observed in the general population and in moderate chronic kidney disease can be extended to the hemodialysis population. VKA may be especially harmful in dialysis patients and should therefore be avoided, in particular in patients with a high bleeding risk and labile international normalized ratio. Dose-finding studies of DOAC suggest that rivaroxaban 10 mg daily and apixaban 2.5 mg twice daily are appropriate choices in dialysis patients. Combined treatment of oral anticoagulants and antiplatelet agents should be reserved for strong indications and limited in time. Left atrial appendage occlusion is a potential attractive solution to reduce the risk of stroke without increasing bleeding propensity, but has not been properly studied in dialysis patients.
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Affiliation(s)
- An S De Vriese
- Division of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge, Brugge, and Ghent University, Ghent, Belgium
| | - Gunnar Heine
- AGAPLESION MARKUS KRANKENHAUS, Frankfurt, and Saarland University Faculty of Medicine, Homburg, Germany
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Dittrich T, Polymeris A, De Marchis GM. Challenges of treatment adherence with direct oral anticoagulants in pandemic. Curr Opin Neurol 2021; 34:38-44. [PMID: 33230038 DOI: 10.1097/wco.0000000000000888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Direct oral anticoagulants (DOAC) are crucial for the prevention of thromboembolic events in patients with nonvalvular atrial fibrillation. Drug adherence by the patient but also adherence to guidelines by the physician are suboptimal. This review highlights aspects of DOAC treatment during the coronavirus disease 2019 (COVID-19) pandemic and selected challenging scenarios. RECENT FINDINGS For patients with a newly diagnosed indication for oral anticoagulation, a new interim clinical guidance recommends starting DOAC instead of vitamin K antagonists if DOAC are not contraindicated. The goal is to reduce the potential exposure of patients to severe acute respiratory syndrome coronavirus during the routine coagulation monitoring visits. As COVID-19 can lead to kidney failure, we discuss the challenges of DOAC dosing in kidney failures. Finally, we discuss two common challenges - when to start a DOAC after an ischemic stroke linked to atrial fibrillation, and whether cerebral microbleeds, including their count, are per se a contraindication to DOAC. SUMMARY There are still open challenges regarding DOAC treatment on the patient and physician side, both related and unrelated to the pandemic.
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Affiliation(s)
- Tolga Dittrich
- Department of Neurology and Stroke Center, University Hospital Basel
| | | | - Gian Marco De Marchis
- Department of Neurology and Stroke Center, University Hospital Basel
- Medical Faculty of the University of Basel, Basel, Switzerland
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Premužić V, Stevanović R, Radić P, Salvetti M, Lovrić-Benčić M, Jelaković A, Miličić D, Capak K, Agabiti-Rosei E, Jelaković B. Chronic kidney disease and cardiovascular mortality in patients with atrial fibrillation: European Society of Hypertension project - ESH A Fib. Medicine (Baltimore) 2021; 100:e23975. [PMID: 33466138 PMCID: PMC7808501 DOI: 10.1097/md.0000000000023975] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 11/30/2020] [Indexed: 01/05/2023] Open
Abstract
Our aim was to analyze characteristics of atrial fibrillation (AF) patients with chronic kidney disease (CKD) from the Croatian cohort of the ESH A Fib survey and to determine the association of estimated glomerular filtration rate (eGFR) with cardiovascular (CV) mortality after 24 months of follow-up.Consecutive sample of 301 patients with AF were enrolled in the period 2014 to 2018. Hypertension was defined as BP > 140/90 mm Hg and/or antihypertensive drugs treatment, CKD was defined as eGFR (CKD Epi) < 60 ml/min/1.73 m2 which was confirmed after 3 months.CKD was diagnosed in 45.2% of patients (13.3% in CKD stage > 3b). CKD patients were older than non-CKD and had significantly more frequent coronary heart disease, heart failure and valvular disease. CKD patients had significantly higher CHA2DS2-VASc score and more CKD than non-CKD patients had CHA2DS2-VASc > 2. Crude CV mortality rate per 1000 population at the end of the first year of the follow-up was significantly higher in CKD vs non-CKD group who had shorter mean survival time. CV mortality was independently associated with eGFR, male gender, CHA2DS2VASc and R2CHA2DS2VASc scores.Prevalence of CKD, particularly more advanced stages of CKD, is very high in patients with AF. Observed higher CV mortality and shorter mean survival time in CKD patients could be explained with higher CHA2DS2VASc score which is a consequence of clustering of all score components in CKD patients. However, eGFR was independently associated with CV mortality. In our cohort, R2CHA2DS2VASc score was not associated significantly more with CV mortality than CHA2DS2VASc score.
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Affiliation(s)
- Vedran Premužić
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Center Zagreb
- School of Medicine, Zagreb, Croatia
| | | | - Petra Radić
- University Hospital Center Sisters of Mercy, Zagreb, Croatia
| | | | - Martina Lovrić-Benčić
- Cardiology Clinic, University Hospital Center Zagreb
- School of Medicine, Zagreb, Croatia
| | - Ana Jelaković
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Center Zagreb
| | - Davor Miličić
- Cardiology Clinic, University Hospital Center Zagreb
- School of Medicine, Zagreb, Croatia
| | | | | | - Bojan Jelaković
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Center Zagreb
- School of Medicine, Zagreb, Croatia
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Kang Y, Choi HY, Kwon YE, Shin JH, Won EM, Yang KH, Oh HJ, Ryu DR. Clinical outcomes among hemodialysis patients with atrial fibrillation: a Korean nationwide population-based study. Kidney Res Clin Pract 2021; 40:99-108. [PMID: 33789385 PMCID: PMC8041641 DOI: 10.23876/j.krcp.20.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 09/10/2020] [Indexed: 12/01/2022] Open
Abstract
Background The number of patients requiring dialysis is increasing worldwide, and the atrial fibrillation and atrial flutter (AF) prevalence among hemodialysis (HD) patients is higher than in the general population. There have been no studies of Korean AF patients undergoing HD that investigated how AF affects outcomes, such as all-cause mortality, hospitalization, and stroke events. We conducted a large-scale retrospective cohort study with data from the National Health Insurance System to determine how AF affects these outcomes. Methods In 2013, the Health Insurance Review and Assessment service, a Korean national health insurance scheme, collected data from 21,839 HD patients to evaluate the adequacy of dialysis centers. All-cause mortality, hospitalization, and stroke events were compared between patients with and without AF. Sub-analyses compared these outcomes between AF patients receiving warfarin and those not receiving warfarin. Results Cox regression analysis found that AF was a significant risk factor for death from any cause (hazard ratio [HR], 1.356; 95% confidence interval [CI], 1.222–1.506; p < 0.001), hospitalization (HR, 1.323; 95% CI, 1.225–1.430; p < 0.001), and hemorrhagic stroke (HR, 1.500; 95% CI, 1.050–2.141; p = 0.026). AF was not significantly associated with an increased risk of ischemic stroke. The use of warfarin was significantly associated with hemorrhagic stroke incidence (HR, 1.593; 95% CI, 1.075–2.360; p = 0.020), while there was no significant correlation between warfarin treatment and all-cause mortality, hospitalization, and ischemic stroke. Conclusion This cohort study of Korean dialysis patients showed that AF was a risk factor for multiple outcomes among HD patients.
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Affiliation(s)
- Yeunmi Kang
- Department of Internal Medicine, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
| | - Hyung Yun Choi
- The Korean Society of Nephrology, Seoul, Republic of Korea
| | - Young Eun Kwon
- Department of Internal Medicine, Myongji Hospital, Hanyang University College of Medicine, Goyang, Republic of Korea
| | - Ji Hyeon Shin
- Health Insurance Review and Assessment Service, Wonju, Republic of Korea
| | - Eun Mi Won
- Health Insurance Review and Assessment Service, Wonju, Republic of Korea
| | - Ki Hwa Yang
- Health Insurance Review and Assessment Service, Wonju, Republic of Korea
| | - Hyung Jung Oh
- Ewha Institute of Convergence Medicine, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea.,Research Institute for Human Health Information, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
| | - Dong-Ryeol Ryu
- Research Institute for Human Health Information, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Republic of Korea
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Pavlova TV. An Elderly Comorbid Patient with Atrial Fibrillation: What is Important to Know and What Should be Considered When Prescribing Anticoagulants? RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2020. [DOI: 10.20996/1819-6446-2020-12-05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Anticoagulant therapy in elderly patients with atrial fibrillation and concomitant diseases is often the challenge for clinicians. The high risk of stroke is inherent in atrial fibrillation, and it increases when combined with coronary heart disease and chronic kidney disease. On the other hand, the comorbidity increases the risk of bleeding. Older age is also the risk factor of thrombotic and hemorrhagic complications. As a consequence, the choice of specific anticoagulant should be based on a solid evidences, obtained both from randomized clinical trials and from daily clinical practice. In the ROCKET AF trail the direct oral anticoagulant rivaroxaban showed a tendency to reduce the risk of thromboembolism by 20% compared with warfarin in the patients aged 75 years and older. The safety of rivaroxaban has been evaluated in the XANTUS POOLED program. According to the follow-up results for 12 months, more than 96% of patients didn't have any adverse event, and the number of patients with major bleeding was 1.5%. Several meta-analyzes reported a reduction of cardiovascular complications in patients treated by rivaroxaban. In the ROCKET AF trail, a “renal” dose of rivaroxaban (15 mg OD) was studied in patients with chronic kidney disease. The efficacy and safety of rivaroxaban were validated in this patients, and a simple algorithm for selecting the dose of this drug in patients with chronic kidney disease was provided.
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Seghers CB, Ver Elst K, Claessens J, Weekx S, Vermeiren S, Henckes M. A New Method for the Measurement of International Normalized Ratio in Hemodialysis Patients with Heparin-Locked Tunneled Dialysis Catheters. Int J Nephrol 2020; 2020:7586437. [PMID: 33425390 PMCID: PMC7772028 DOI: 10.1155/2020/7586437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 11/08/2020] [Accepted: 12/07/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND To measure International Normalized Ratio (INR) in hemodialysis patients with tunneled dialysis catheters (TDCs), blood sampling is frequently obtained via the catheter at the start of the session. INR measurements via finger-prick point of care testing (POCT) and via blood sampling taken from the dialysis circuit are evaluated as alternatives. METHODS In 14 hemodialysis patients with TDCs, treated with vitamin K antagonists (VKA), INR measurements via POCT were compared with plasma INR samples taken via the catheter at the start of dialysis and via the dialysis circuit after 30 and 60 minutes during 3 nonconsecutive dialysis sessions. RESULTS Blood samples taken at the start of dialysis at the catheter site were frequently contaminated with heparin originating from the locking solution (unfractionated heparin concentration (UFH) >1.0 IU/ml in 13.2%). POCT INR at the start of dialysis was not different from plasma INR after 30 and 60 minutes (Wilcoxon test p=0.113, n = 37, and p=0.631, n = 36, respectively). Moreover, there was no difference between POCT INR at the start of dialysis and POCT INR after 30 and 60 minutes (Wilcoxon test p=0.797 and p = 0.801, respectively; n = 36). Passing and Bablok regression equation was used, y = 0.460 + 0.733x; n = 105. Treatment decisions based on these 2 methods showed a very good overall agreement (kappa = 0.810; 95% CI: 0.732-0.889; n = 105). CONCLUSIONS Measuring plasma INR via the TDC at the start of dialysis should be abandoned. Measuring POCT INR via a finger prick at the start or even after 30 to 60 minutes is an alternative. The most elegant alternative is to take plasma INR samples via the dialysis circuit 30 minutes or later after the start of the dialysis.
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Affiliation(s)
- Céline B. Seghers
- Department of Nephrology, GZA Ziekenhuizen, Campus Sint-Augustinus, Oosterveldlaan 24, Wilrijk 2610, Belgium
| | - Kristien Ver Elst
- Department of Laboratory Medicine, GZA Ziekenhuizen, Campus Sint-Augustinus, Oosterveldlaan 24, Wilrijk 2610, Belgium
| | - Jolien Claessens
- Department of Laboratory Medicine, GZA Ziekenhuizen, Campus Sint-Augustinus, Oosterveldlaan 24, Wilrijk 2610, Belgium
| | - Steven Weekx
- Department of Laboratory Medicine, GZA Ziekenhuizen, Campus Sint-Augustinus, Oosterveldlaan 24, Wilrijk 2610, Belgium
| | - Sigrid Vermeiren
- Department of Laboratory Medicine, GZA Ziekenhuizen, Campus Sint-Augustinus, Oosterveldlaan 24, Wilrijk 2610, Belgium
| | - Manu Henckes
- Department of Nephrology, GZA Ziekenhuizen, Campus Sint-Augustinus, Oosterveldlaan 24, Wilrijk 2610, Belgium
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