Oral anticoagulation in patients with chronic kidney disease: A systematic review and meta-analysis

Konark Malhotra, Muhammad F. Ishfaq, Nitin Goyal, Aristeidis H. Katsanos, John Parissis, Anne W. Alexandrov, Andrei V. Alexandrov, Georgios Tsivgoulis

Research output: Contribution to journalArticle

Abstract

ObjectiveData regarding the efficacy and safety of warfarin and non-vitamin K antagonist oral anticoagulant (NOAC) among patients with chronic kidney disease (CKD) remain scarce.MethodsSystematic review and meta-analysis of studies involving patients with CKD treated with oral anticoagulants were conducted to evaluate the following outcomes: ischemic stroke, intracerebral hemorrhage (ICH), combined ischemic and hemorrhagic stroke (strokecombined), stroke or systemic embolism, mortality, and major bleeding events. CKD was defined based on creatinine clearance (CrCl) ranging from mild (CrCl: 60-89 mL/min), moderate (CrCl: 30-59 mL/min), to severe (CrCl: 15-29 mL/min).ResultsFifteen studies (7 comparing NOAC vs warfarin and 8 comparing warfarin vs no anticoagulant) were identified comprising 78,053 patients. Warfarin (vs no anticoagulant) was associated with reduced risk of ischemic stroke (risk ratio [RR] = 0.68; 95% confidence interval [CI] 0.55-0.84]) and mortality (RR = 0.70; 95% CI 0.62-0.78). In comparison to warfarin, NOAC use lowered the risk of ICH (RR = 0.43; 95% CI 0.33-0.56), strokecombined (RR = 0.83; 95% CI 0.72-0.96), stroke or systemic embolism (RR = 0.73; 95% CI 0.62-0.85), and major bleeding (RR = 0.77; 95% CI 0.66-0.90). In adjusted analyses, warfarin use (vs no anticoagulant) was associated with reduced mortality (HRadj = 0.68; 95% CI 0.61-0.76), whereas NOAC (vs warfarin) use reduced the risk of ICH (HRadj = 0.39; 95% CI 0.30-0.50) and stroke or systemic embolism (HRadj = 0.75; 95% CI 0.65-0.88). Our sensitivity analyses comparing different NOACs exhibited that factor Xa inhibitors (compared to warfarin) consistently reduced strokecombined (RR = 0.84; 95% CI 0.73-0.96), mortality (RR = 0.84; 95% CI 0.70-1.00), ICH (RR = 0.45; 95% CI 0.24-0.85), and major bleeding (RR = 0.76; 95% CI 0.64-0.91).ConclusionsAmong patients with CKD treated with oral anticoagulants, NOACs present with a more favorable safety and efficacy profile for various cardiovascular outcomes.

Original languageEnglish (US)
Pages (from-to)e2421-e2431
JournalNeurology
Volume92
Issue number21
DOIs
StatePublished - May 21 2019

Fingerprint

Chronic Renal Insufficiency
Meta-Analysis
Confidence Intervals
Warfarin
Anticoagulants
Odds Ratio
Stroke
Cerebral Hemorrhage
Creatinine
Embolism
Mortality
Hemorrhage
Safety

All Science Journal Classification (ASJC) codes

  • Clinical Neurology

Cite this

Oral anticoagulation in patients with chronic kidney disease : A systematic review and meta-analysis. / Malhotra, Konark; Ishfaq, Muhammad F.; Goyal, Nitin; Katsanos, Aristeidis H.; Parissis, John; Alexandrov, Anne W.; Alexandrov, Andrei V.; Tsivgoulis, Georgios.

In: Neurology, Vol. 92, No. 21, 21.05.2019, p. e2421-e2431.

Research output: Contribution to journalArticle

Malhotra, K, Ishfaq, MF, Goyal, N, Katsanos, AH, Parissis, J, Alexandrov, AW, Alexandrov, AV & Tsivgoulis, G 2019, 'Oral anticoagulation in patients with chronic kidney disease: A systematic review and meta-analysis', Neurology, vol. 92, no. 21, pp. e2421-e2431. https://doi.org/10.1212/WNL.0000000000007534
Malhotra, Konark ; Ishfaq, Muhammad F. ; Goyal, Nitin ; Katsanos, Aristeidis H. ; Parissis, John ; Alexandrov, Anne W. ; Alexandrov, Andrei V. ; Tsivgoulis, Georgios. / Oral anticoagulation in patients with chronic kidney disease : A systematic review and meta-analysis. In: Neurology. 2019 ; Vol. 92, No. 21. pp. e2421-e2431.
@article{dc638eaf1324405ba26b903f3228fe14,
title = "Oral anticoagulation in patients with chronic kidney disease: A systematic review and meta-analysis",
abstract = "ObjectiveData regarding the efficacy and safety of warfarin and non-vitamin K antagonist oral anticoagulant (NOAC) among patients with chronic kidney disease (CKD) remain scarce.MethodsSystematic review and meta-analysis of studies involving patients with CKD treated with oral anticoagulants were conducted to evaluate the following outcomes: ischemic stroke, intracerebral hemorrhage (ICH), combined ischemic and hemorrhagic stroke (strokecombined), stroke or systemic embolism, mortality, and major bleeding events. CKD was defined based on creatinine clearance (CrCl) ranging from mild (CrCl: 60-89 mL/min), moderate (CrCl: 30-59 mL/min), to severe (CrCl: 15-29 mL/min).ResultsFifteen studies (7 comparing NOAC vs warfarin and 8 comparing warfarin vs no anticoagulant) were identified comprising 78,053 patients. Warfarin (vs no anticoagulant) was associated with reduced risk of ischemic stroke (risk ratio [RR] = 0.68; 95{\%} confidence interval [CI] 0.55-0.84]) and mortality (RR = 0.70; 95{\%} CI 0.62-0.78). In comparison to warfarin, NOAC use lowered the risk of ICH (RR = 0.43; 95{\%} CI 0.33-0.56), strokecombined (RR = 0.83; 95{\%} CI 0.72-0.96), stroke or systemic embolism (RR = 0.73; 95{\%} CI 0.62-0.85), and major bleeding (RR = 0.77; 95{\%} CI 0.66-0.90). In adjusted analyses, warfarin use (vs no anticoagulant) was associated with reduced mortality (HRadj = 0.68; 95{\%} CI 0.61-0.76), whereas NOAC (vs warfarin) use reduced the risk of ICH (HRadj = 0.39; 95{\%} CI 0.30-0.50) and stroke or systemic embolism (HRadj = 0.75; 95{\%} CI 0.65-0.88). Our sensitivity analyses comparing different NOACs exhibited that factor Xa inhibitors (compared to warfarin) consistently reduced strokecombined (RR = 0.84; 95{\%} CI 0.73-0.96), mortality (RR = 0.84; 95{\%} CI 0.70-1.00), ICH (RR = 0.45; 95{\%} CI 0.24-0.85), and major bleeding (RR = 0.76; 95{\%} CI 0.64-0.91).ConclusionsAmong patients with CKD treated with oral anticoagulants, NOACs present with a more favorable safety and efficacy profile for various cardiovascular outcomes.",
author = "Konark Malhotra and Ishfaq, {Muhammad F.} and Nitin Goyal and Katsanos, {Aristeidis H.} and John Parissis and Alexandrov, {Anne W.} and Alexandrov, {Andrei V.} and Georgios Tsivgoulis",
year = "2019",
month = "5",
day = "21",
doi = "10.1212/WNL.0000000000007534",
language = "English (US)",
volume = "92",
pages = "e2421--e2431",
journal = "Neurology",
issn = "0028-3878",
publisher = "Lippincott Williams and Wilkins",
number = "21",

}

TY - JOUR

T1 - Oral anticoagulation in patients with chronic kidney disease

T2 - A systematic review and meta-analysis

AU - Malhotra, Konark

AU - Ishfaq, Muhammad F.

AU - Goyal, Nitin

AU - Katsanos, Aristeidis H.

AU - Parissis, John

AU - Alexandrov, Anne W.

AU - Alexandrov, Andrei V.

AU - Tsivgoulis, Georgios

PY - 2019/5/21

Y1 - 2019/5/21

N2 - ObjectiveData regarding the efficacy and safety of warfarin and non-vitamin K antagonist oral anticoagulant (NOAC) among patients with chronic kidney disease (CKD) remain scarce.MethodsSystematic review and meta-analysis of studies involving patients with CKD treated with oral anticoagulants were conducted to evaluate the following outcomes: ischemic stroke, intracerebral hemorrhage (ICH), combined ischemic and hemorrhagic stroke (strokecombined), stroke or systemic embolism, mortality, and major bleeding events. CKD was defined based on creatinine clearance (CrCl) ranging from mild (CrCl: 60-89 mL/min), moderate (CrCl: 30-59 mL/min), to severe (CrCl: 15-29 mL/min).ResultsFifteen studies (7 comparing NOAC vs warfarin and 8 comparing warfarin vs no anticoagulant) were identified comprising 78,053 patients. Warfarin (vs no anticoagulant) was associated with reduced risk of ischemic stroke (risk ratio [RR] = 0.68; 95% confidence interval [CI] 0.55-0.84]) and mortality (RR = 0.70; 95% CI 0.62-0.78). In comparison to warfarin, NOAC use lowered the risk of ICH (RR = 0.43; 95% CI 0.33-0.56), strokecombined (RR = 0.83; 95% CI 0.72-0.96), stroke or systemic embolism (RR = 0.73; 95% CI 0.62-0.85), and major bleeding (RR = 0.77; 95% CI 0.66-0.90). In adjusted analyses, warfarin use (vs no anticoagulant) was associated with reduced mortality (HRadj = 0.68; 95% CI 0.61-0.76), whereas NOAC (vs warfarin) use reduced the risk of ICH (HRadj = 0.39; 95% CI 0.30-0.50) and stroke or systemic embolism (HRadj = 0.75; 95% CI 0.65-0.88). Our sensitivity analyses comparing different NOACs exhibited that factor Xa inhibitors (compared to warfarin) consistently reduced strokecombined (RR = 0.84; 95% CI 0.73-0.96), mortality (RR = 0.84; 95% CI 0.70-1.00), ICH (RR = 0.45; 95% CI 0.24-0.85), and major bleeding (RR = 0.76; 95% CI 0.64-0.91).ConclusionsAmong patients with CKD treated with oral anticoagulants, NOACs present with a more favorable safety and efficacy profile for various cardiovascular outcomes.

AB - ObjectiveData regarding the efficacy and safety of warfarin and non-vitamin K antagonist oral anticoagulant (NOAC) among patients with chronic kidney disease (CKD) remain scarce.MethodsSystematic review and meta-analysis of studies involving patients with CKD treated with oral anticoagulants were conducted to evaluate the following outcomes: ischemic stroke, intracerebral hemorrhage (ICH), combined ischemic and hemorrhagic stroke (strokecombined), stroke or systemic embolism, mortality, and major bleeding events. CKD was defined based on creatinine clearance (CrCl) ranging from mild (CrCl: 60-89 mL/min), moderate (CrCl: 30-59 mL/min), to severe (CrCl: 15-29 mL/min).ResultsFifteen studies (7 comparing NOAC vs warfarin and 8 comparing warfarin vs no anticoagulant) were identified comprising 78,053 patients. Warfarin (vs no anticoagulant) was associated with reduced risk of ischemic stroke (risk ratio [RR] = 0.68; 95% confidence interval [CI] 0.55-0.84]) and mortality (RR = 0.70; 95% CI 0.62-0.78). In comparison to warfarin, NOAC use lowered the risk of ICH (RR = 0.43; 95% CI 0.33-0.56), strokecombined (RR = 0.83; 95% CI 0.72-0.96), stroke or systemic embolism (RR = 0.73; 95% CI 0.62-0.85), and major bleeding (RR = 0.77; 95% CI 0.66-0.90). In adjusted analyses, warfarin use (vs no anticoagulant) was associated with reduced mortality (HRadj = 0.68; 95% CI 0.61-0.76), whereas NOAC (vs warfarin) use reduced the risk of ICH (HRadj = 0.39; 95% CI 0.30-0.50) and stroke or systemic embolism (HRadj = 0.75; 95% CI 0.65-0.88). Our sensitivity analyses comparing different NOACs exhibited that factor Xa inhibitors (compared to warfarin) consistently reduced strokecombined (RR = 0.84; 95% CI 0.73-0.96), mortality (RR = 0.84; 95% CI 0.70-1.00), ICH (RR = 0.45; 95% CI 0.24-0.85), and major bleeding (RR = 0.76; 95% CI 0.64-0.91).ConclusionsAmong patients with CKD treated with oral anticoagulants, NOACs present with a more favorable safety and efficacy profile for various cardiovascular outcomes.

UR - http://www.scopus.com/inward/record.url?scp=85066456004&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85066456004&partnerID=8YFLogxK

U2 - 10.1212/WNL.0000000000007534

DO - 10.1212/WNL.0000000000007534

M3 - Article

C2 - 31068485

AN - SCOPUS:85066456004

VL - 92

SP - e2421-e2431

JO - Neurology

JF - Neurology

SN - 0028-3878

IS - 21

ER -