16 Jul Oral Anticoagulant in Chronic Kidney Disease: Benefits and Harms
MedicalResearch.com Interview with:
Sunil Badve MBBS, MD, DNB, FRACP, PhD, FASN
Senior Research Fellow, Renal & Metabolic Division
Staff specialist nephrologist | St George Hospital
University of New South Wales
The George Institute for Global Health
MedicalResearch.com: What is the background for this study?
Response: Despite the high prevalence of cardiovascular thrombotic events and venous thromboembolism (VTE) in chronic kidney disease (CKD), oral anticoagulant therapy is often underutilized in patients with advanced CKD and dialysis-dependent end-stage kidney disease (ESKD) due to uncertainty of benefit and potential bleeding complications. This comprehensive systematic review was performed to study the benefits and harms of oral anticoagulant therapy in patients with CKD.
MedicalResearch.com: What are the main findings?
Response: Forty-five randomized controlled trials involving 34,082 participants with CKD anticoagulated for atrial fibrillation (AF), acute VTE treatment, thromboprophylaxis, prevention of dialysis-access thrombosis, and cardiovascular disease other than AF were included in the systematic review. All but the eight trials involving ESKD patients excluded participants with advanced stages of CKD.
In patients with AF and early-stage CKD, non-vitamin K oral anticoagulants (NOACs) were superior to vitamin K antagonists (VKAs), with relative risk reductions of 21% for stroke or systemic embolism, 52% for hemorrhagic stroke, and 51% for intracranial hemorrhage. Compared with placebo, NOACs reduced risk for recurrent VTE or VTE-related death in patients with CKD receiving acute VTE treatment; however, compared with VKAs, this effect was uncertain. When all trials were combined, compared with VKAs, high-dose NOACs reduced risk for major bleeding, although this result was not statistically significant.
MedicalResearch.com: What should readers take away from your report?
Response: In patients with early stages of CKD and AF who need anticoagulation for stroke prevention, high dose NOACs should be considered over VKAs. NOACs may be a reasonable treatment option for patients with CKD who develop acute VTE. However, there is insufficient evidence to conclude whether patients with advanced stages of CKD or ESKD derive benefit from VKA or NOAC. In these patients, treatment should be based on individual risk-benefit assessment.
MedicalResearch.com: What recommendations do you have for future research as a result of this work?
Response: Adequately powered randomized trials are required to evaluate the benefits and harms of anticoagulant therapy in patients with AF and advanced stages of CKD or ESKD.
Dr. Badve reports grants from the National Health and Medical Research Council of Australia, personal fees from Bayer AG, and nonfinancial support from Bayer AG during the conduct of the study.
Benefits and Harms of Oral Anticoagulant Therapy in Chronic
Kidney Disease: A Systematic Review and Meta-analysis
Jeffrey T. Ha, MBBS; Brendon L. Neuen, MBBS(Hons); Lap P. Cheng, MBBS; Min Jun, PhD; Tadashi Toyama, PhD; Martin P. Gallagher, PhD; Meg J. Jardine, PhD; Manish M. Sood, MD; Amit X. Garg, PhD; Suetonia C. Palmer, PhD; Patrick B. Mark, PhD; David C. Wheeler, MD; Vivekanand Jha, MD; Ben Freedman, PhD; David W. Johnson, PhD; Vlado Perkovic, PhD; Sunil V. Badve, PhD
Ann Intern Med. 2019.
DOI: 10.7326/M19-0087 2019 American College of Physicians
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