Author + information
- Received June 27, 2017
- Revision received August 31, 2017
- Accepted September 25, 2017
- Published online November 20, 2017.
- Xiaoxi Yao, PhDa,b,∗ (, )
- Navdeep Tangri, MD, PhDc,
- Bernard J. Gersh, MB, ChB, DPhild,
- Lindsey R. Sangaralingham, MPHa,
- Nilay D. Shah, PhDa,b,e,
- Karl A. Nath, MB, ChBf and
- Peter A. Noseworthy, MDa,d
- aRobert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- bDivision of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
- cDepartment of Medicine, Chronic Disease Innovation Center and University of Manitoba, Winnipeg, Manitoba, Canada
- dDepartment of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- eOptumLabs, Cambridge, Massachusetts
- fDivision of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
- ↵∗Address for correspondence:
Dr. Xiaoxi Yao, Mayo Clinic, 200 First Street Southwest, Rochester, Minnesota 55905.
Background Lifelong oral anticoagulation, either with warfarin or a non–vitamin K antagonist oral anticoagulant (NOAC), is indicated for stroke prevention in most patients with atrial fibrillation (AF). Emerging evidence suggests that NOACs may be associated with better renal outcomes than warfarin.
Objectives This study aimed to compare 4 oral anticoagulant agents (apixaban, dabigatran, rivaroxaban, and warfarin) for their effects on 4 renal outcomes: ≥30% decline in estimated glomerular filtration rate (eGFR), doubling of the serum creatinine level, acute kidney injury (AKI), and kidney failure.
Methods Using a large U.S. administrative database linked to laboratory results, the authors identified 9,769 patients with nonvalvular AF who started taking an oral anticoagulant agent between October 1, 2010 and April 30, 2016. Inverse probability of treatment weighting was used to balance more than 60 baseline characteristics among patients in the 4 drug cohorts. Cox proportional hazards regression was performed in the weighted population to compare oral anticoagulant agents.
Results The cumulative risk at the end of 2 years for each outcome was 24.4%, 4.0%, 14.8%, and 1.7% for ≥30% decline in eGFR, doubling of serum creatinine, AKI, and kidney failure, respectively. When the 3 NOACs were pooled, they were associated with reduced risks of ≥30% decline in eGFR (hazard ratio [HR]: 0.77; 95% confidence interval [CI]: 0.66 to 0.89; p < 0.001), doubling of serum creatinine (HR: 0.62; 95% CI: 0.40 to 0.95; p = 0.03), and AKI (HR: 0.68; 95% CI: 0.58 to 0.81; p < 0.001) compared with warfarin. When comparing each NOAC with warfarin, dabigatran was associated with lower risks of ≥30% decline in eGFR and AKI; rivaroxaban was associated with lower risks of ≥30% decline in eGFR, doubling of serum creatinine, and AKI; however, apixaban did not have a statistically significant relationship with any of the renal outcomes.
Conclusions Renal function decline is common among patients with AF treated with oral anticoagulant agents. NOACs, particularly dabigatran and rivaroxaban, may be associated with lower risks of adverse renal outcomes than warfarin.
This study was funded by the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, which receives no industry funding. Dr. Gersh serves on the data and safety monitoring board for Janssen Research & Development, Mount Sinai St. Luke’s, Boston Scientific, Teva, St. Jude Medical, Thrombosis Research Institute, Duke Clinical Research Institute, Kowa Research Institute, and Cardiovascular Research Foundation; and provides general consulting for Janssen Scientific Affairs (formerly known as Ortho-McNeil), Xenon Pharmaceuticals, and Sirtex Medical. Dr. Tangri has received a research grant from AstraZeneca; and has received honoraria from Otsuka. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received June 27, 2017.
- Revision received August 31, 2017.
- Accepted September 25, 2017.
- 2017 American College of Cardiology Foundation