Abstract
BACKGROUND: Patients with chronic kidney disease (CKD) have an increased risk of venous thromboembolism (VTE) and atrial fibrillation (AF). Anticoagulants have not been studied in randomised controlled trials with CrCl < 30 ml/min. The objective of this review was to identify the impact of different anticoagulant strategies in patients with advanced CKD including dialysis.
METHODS: We conducted a systematic review of randomized controlled trials and cohort studies, searching electronic databases from 1946 to 2022. Studies that evaluated both thrombotic and bleeding outcomes with anticoagulant use in CrCl < 50 ml/min were included.
RESULTS: Our initial search yielded 14,503 papers with 53 suitable for inclusion. RCTs comparing direct oral anticoagulants (DOACs) versus warfarin for patients with VTE and CrCl 30-50 ml/min found no difference in recurrent VTE events (RR 0.68(95% CI 0.42-1.11)) with reduced bleeding (RR 0.65 (95% CI 0.45-0.94)). Observational data in haemodialysis suggest lower risk of recurrent VTE and major bleeding with apixaban versus warfarin. Very few studies examining outcomes were available for therapeutic and prophylactic dose low molecular weight heparin for CrCl < 30 ml/min. Findings for patients with AF on dialysis were that warfarin or DOACs had a similar or higher risk of stroke compared to no anticoagulation. For patients with AF and CrCl < 30 ml/min not on dialysis, anticoagulation should be considered on an individual basis, with limited studies suggesting DOACs may have a preferable safety profile.
CONCLUSION: Further studies are still required, some ongoing, in patients with advanced CKD (CrCl < 30 ml/min) to identify the safest and most effective treatment options for VTE and AF.
| Original language | English |
|---|---|
| Pages (from-to) | 2015-2033 |
| Number of pages | 19 |
| Journal | Journal of Nephrology |
| Volume | 35 |
| Issue number | 8 |
| Early online date | 25 Aug 2022 |
| DOIs | |
| Publication status | Published - 1 Nov 2022 |
Bibliographical note
Funding Information:Thank you to the University of Manchester specialist librarians who supported with the search strategy design.
Funding Information:
KP is supported by the National Institute for Health Research (HEE/NIHR ICA Programme Clinical Doctoral Research Fellowship, Miss Kathrine Parker, NIHR300545). SM is supported by NIHR Infrastructure in Manchester and Devices for Dignity MIC, Sheffield. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care.
Publisher Copyright:
© 2022, The Author(s).
Keywords
- Humans
- Anticoagulants/adverse effects
- Warfarin/adverse effects
- Venous Thromboembolism/drug therapy
- Administration, Oral
- Atrial Fibrillation/complications
- Hemorrhage/chemically induced
- Renal Insufficiency, Chronic/complications
- Heparin, Low-Molecular-Weight/therapeutic use