Clinical Outcomes of Warfarin Initiation in Advanced Chronic Kidney Disease Patients With Incident Atrial Fibrillation.
Clinical Outcomes of Warfarin Initiation in Advanced Chronic Kidney Disease Patients With Incident Atrial Fibrillation.
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DOI：
10.1016/j.jacep.2020.06.036
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发表时间：
2020-12-14
期刊：
影响因子：
--
通讯作者：
Kovesdy CP
中科院分区：
文献类型：
--
作者：
Agarwal MA;Potukuchi PK;Sumida K;Naseer A;Molnar MZ;George LK;Koshy SK;Streja E;Thomas F;Kalantar-Zadeh K;Kovesdy CP
在转为透析的晚期慢性肾脏病（CKD）患者中，华法林治疗在房颤（AF）诊断后用于血栓预防的临床获益尚不清楚。本研究的目的是检查在转为透析的晚期CKD患者中诊断为AF后开始华法林治疗的疗效和安全性。在这项回顾性队列分析中，研究人群为22，771名患有终末期肾病（ESRD）的美国退伍军人的国家队列，这些退伍军人在开始肾脏替代治疗前发生了AF事件。我们在校正人口统计学特征和合并症的多变量校正考克斯回归分析中，检查了诊断为AF事件后华法林治疗与缺血性脑血管意外（CVA）（缺血性卒中或短暂性脑缺血发作）、缺血性CVA相关住院、大出血事件（胃肠道或颅内出血）、出血事件相关住院和透析后全因死亡率的相关性。队列的平均（SD）年龄为73.5±8.8岁，13%为非洲裔美国人，平均CHA 2DS 2-VASc评分为5.7±2.1。在整个队列中，6，682例（29.3%）患者在随访期间开始接受华法林治疗。与未接受抗凝治疗的患者相比，开始接受华法林治疗的患者缺血性CVA、出血事件和死亡的风险比（95%置信区间）分别为1.23（1.16 - 1.30）、1.36（1.29 - 1.44）和0.94（0.90 - 0.97）。暴露于华法林与缺血性CVA和出血事件相关住院的风险较高相关。在晚期CKD患者过渡到透析，华法林的使用与缺血和出血事件的风险较高，但死亡率的风险较低。需要进一步研究，例如比较华法林与新型口服抗凝剂的研究，以明确抗凝治疗对晚期CKD患者房颤事件的净临床获益。社交媒体（Twitter）使用总结：晚期慢性肾脏病（CKD）患者转为透析后，华法林治疗对房颤（AF）诊断后血栓预防的临床获益尚不清楚。我们对一个国家退伍军人人群队列的研究表明，晚期CKD患者使用华法林与缺血和出血事件的风险较高相关，但透析过渡后死亡风险较低。在转为透析的晚期慢性肾脏病（CKD）患者中，华法林治疗在房颤（AF）诊断后用于血栓预防的临床获益尚不清楚。本研究来自美国退伍军人的国家队列，评价了转为透析的晚期CKD患者在诊断为AF后开始华法林治疗的疗效和安全性。我们的研究结果表明，晚期CKD患者使用华法林与缺血性和出血事件的风险较高相关，但终末期肾脏转换后死亡率的风险较低。
The clinical benefit of warfarin therapy for thromboprophylaxis after incident atrial fibrillation (AF) diagnosis in late-stage chronic kidney disease (CKD) patients transitioning to dialysis is unknown. The aim of this study was to examine the efficacy and safety of warfarin initiation following the diagnosis of AF in late-stage CKD patients transitioning to dialysis. In this retrospective cohort analysis, the study population was a national cohort of 22,771 US veterans with incident end stage renal disease (ESRD) who developed incident AF prior to initiating renal replacement therapy. We examined the association of warfarin therapy following the diagnosis of incident AF with ischemic-cerebrovascular accidents (CVA) (ischemic stroke or transient ischemic attack), ischemic-CVA related hospitalization, major bleeding events (gastrointestinal or intracranial bleeding), bleeding event related hospitalizations and post-dialysis all-cause mortality in multivariable adjusted Cox regression analyses adjusting for demographic characteristics and comorbidities. The mean (SD) age of the cohort was 73.5±8.8 years, 13% were African American and the mean CHA2DS2-VASc score was 5.7±2.1. Among overall cohort, 6,682 (29.3%) patients were started on warfarin during the follow up period. The hazard ratios (95% confidence intervals) for ischemic-CVA, bleeding events and death for those started on warfarin were 1.23 (1.16 to 1.30), 1.36 (1.29 to 1.44), and 0.94 (0.90 to 0.97) compared with those who received no anticoagulation. Warfarin exposure was associated with higher risk for ischemic-CVA and bleeding event related hospitalizations also. In late-stage CKD patients transitioning to dialysis, warfarin use was associated with higher risk of ischemic and bleeding events, but lower risk of mortality. Future studies such as those comparing warfarin with newer oral anticoagulant agents are needed to granularly define the net clinical benefit of anticoagulation therapy in advanced CKD patients with incident AF. Summary for use on social media (Twitter): The clinical benefit of warfarin therapy for thromboprophylaxis after incident atrial fibrillation (AF) diagnosis in late-stage chronic kidney disease (CKD) patients transitioning to dialysis is unknown. Our study from a national cohort of veteran population suggest that warfarin use in advanced CKD is associated with higher risk of ischemic and bleeding events, but lower risk of mortality after dialysis transition. The clinical benefit of warfarin therapy for thromboprophylaxis after incident atrial fibrillation (AF) diagnosis in late-stage chronic kidney disease (CKD) patients transitioning to dialysis is unknown. The present study from a national cohort of US veterans evaluates the efficacy and safety of warfarin initiation following the diagnosis of AF in late-stage CKD patients transitioning to dialysis. Our results suggest that warfarin use in advanced CKD is associated with higher risk of ischemic and bleeding events, but lower risk of mortality after end stage renal transition transition.
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Molnar, Miklos Z.;Gosmanova, Elvira O.;Kovesdy, Csaba P.
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