5715Anticoagulant use and associated outcomes in patients with atrial fibrillation and advanced kidney disease

Abstract

Background: Oral anticoagulants (OAC) reduce the risk of stroke but impose the risk of bleeding in patients with atrial fibrillation (AF). In the setting of advanced chronic kidney disease (CKD), the overall net benefit of OAC remains controversial. Purpose(s): Since patients with advanced CKD were excluded from recent pivotal trials of non-vitamin K antagonist oral anticoagulants (NOACs), we aimed to investigate the use and outcomes of warfarin and NOACs in patients with advanced CKD managed in contemporary routine clinical practice. Method(s): Using a large U.S. administrative database, we identify 49,953 patients with AF and stage 4-5 CKD between 10/1/2010-1/31/2016. We used Cox proportional hazards models to assess the relationships between drug exposure and stroke or bleeding outcomes, adjusting for propensity scores calculated based on 59 socio-demographic and clinical characteristics. Result(s): Two-thirds of the patients were not treated with OAC, and a substantial minority (28%) were treated with warfarin. Outcomes were illustrated in the figure and remained unchanged if considering death as a competing risk or using other propensity score methods. Conclusion(s): In patients with advanced CKD, the use of OAC was associated with a reduced risk of stroke without an increase in bleeding. In patients not on dialysis, NOACs were associated with similar risks of stroke, and apixaban was associated with lower risk of bleeding than warfarin. Apixaban may also be a reasonable alternative to warfarin in dialysis patients.