Direct oral anticoagulants for prevention of stroke in atrial fibrillation patients with chronic kidney disease
What is the issue?
Chronic kidney disease (CKD) patients have an increased risk of atrial fibrillation (AF), which can often lead to stroke or systemic embolism. The conventional therapy for preventive AF is dose-adjusted warfarin, but this can increase the risk of bleeding, which necessitates regular therapeutic monitoring. Recently, direct oral anticoagulants (DOAC) have been developed as alternatives to warfarin. We reviewed the evidence on DOAC compared to warfarin for preventing stroke and systemic embolic events in AF patients with CKD.
What did we do?
We found five studies that compared the effects of DOAC (apixaban, dabigatran, edoxaban, and rivaroxaban) and dose-adjusted warfarin. The 12,545 participants in these five studies had non-valvular AF and moderate kidney impairment. These studies presented data on all composite outcomes of stroke and systematic embolic events as the primary efficacy outcome, with major bleeding events as the primary safety outcome. The median follow-up period ranged from 1.8 to 2.8 years. The evidence is accurate as of August 2017.
What did we find?
DOAC probably reduced the incidence of stroke and systemic embolic events as a primary efficacy outcome, compared to warfarin. Further, DOAC might slightly reduce the incidence of major bleeding events as a primary safety outcome, compared to warfarin.
This review demonstrated that DOAC are as likely as warfarin to prevent all strokes and systemic embolic events without increasing major bleeding events among AF patients with CKD. According to GRADE, the quality of the evidence was moderate for the primary efficacy outcome because of concerns with imprecision and low for the primary safety outcome because of concerns with inconsistency and imprecision. The results of this study chiefly apply to CKD stage G3 patients, since we could not assess those with CKD stage G4 or G5.