Which Oral Anticoagulant Is Best in CKD?

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For patients with early CKD, non–vitamin K oral anticoagulants (NOACs) have a better risk-to-benefit profile than vitamin K antagonists (VKAs), concludes a meta-analysis in Annals of Internal Medicine.

In a systematic review of the literature, the researchers identified 45 randomized controlled trials that evaluated the two types of oral anticoagulants for any indication and included data on efficacy or bleeding outcomes. The studies included a total of 34,082 patients with early-stage or advanced CKD or with ESKD.

The most frequent indications were atrial fibrillation (AF) and venous thromboembolism (VTE), 11 trials each. Other indications included cardiovascular disease other

For patients with early CKD, non–vitamin K oral anticoagulants (NOACs) have a better risk-to-benefit profile than vitamin K antagonists (VKAs), concludes a meta-analysis in Annals of Internal Medicine.

In a systematic review of the literature, the researchers identified 45 randomized controlled trials that evaluated the two types of oral anticoagulants for any indication and included data on efficacy or bleeding outcomes. The studies included a total of 34,082 patients with early-stage or advanced CKD or with ESKD.

The most frequent indications were atrial fibrillation (AF) and venous thromboembolism (VTE), 11 trials each. Other indications included cardiovascular disease other than AF, 9 trials; prevention of thrombosis in dialysis access, 8 trials; and thromboprophylaxis, 6 trials. Except for 8 trials enrolling ESKD patients, the studies excluded patients with creatinine clearance less than 20 mL/min or estimated GFR less than 15 mL/min per 1.73 m2. Most of the data came from subgroups of large trials; there was sparse evidence about patients with advanced CKD or ESKD.

On meta-analysis, NOACs were associated with a reduced risk of stroke or systemic embolism in patients with AF, compared with VKAs: risk ratio (RR) 0.79, based on high-quality evidence. Non–vitamin K oral anticoagulants were also associated with a lower risk of hemorrhagic stroke: RR 0.48, based on moderate-quality evidence.

There was no clear difference between the two types of oral anticoagulants for prevention of recurrent VTE or VTE-related mortality. Across all trials, major bleeding risk appeared lower with NOACs: RR 0.75, based on low-quality evidence.

CKD is a prothrombotic state, associated with several indications for oral anticoagulants. However, there are limited data to guide clinical decisions regarding anticoagulant therapy in CKD.

Available evidence suggests that NOACs are preferable to VKAs for patients with early CKD. The review finds scant evidence to determine the benefits or harms of these oral anticoagulants for patients with advanced CKD or ESKD. The authors emphasize the need for further adequately powered randomized trials [Ha JT, et al. Benefits and harms of oral anticoagulant therapy in chronic kidney disease: A systematic review and meta-analysis. Ann Intern Med 2019; 171:181–189].

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