Kidney Disease Patients May Not Be Getting OACs

Sean Pokorney, MD

Many patients with both kidney disease and atrial fibrillation are not being treated with oral anticoagulants, which increases their risk of stroke, according to a new study.

Only around half of patients with chronic kidney disease and atrial fibrillation were treated with oral anticoagulants (OACs), and this proportion decreased significantly as kidney disease became more severe, according to the study presented at the American College of Cardiology Scientific Sessions in March.

Researchers at the Duke Clinical Research Institute (DCRI)were interested in examining how advanced kidney disease affects under-treatment with OACs and how different treatment options affect patient outcomes, according to DCRI’s web site.

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Using the Premier Healthcare Database, which represents 20% of hospital discharges across the United States, the researchers examined data from around 300,000 patients with atrial fibrillation and chronic kidney disease.

The team looked at data from four patient groups: those treated with warfarin (Coumadin), those treated with newer direct oral anticoagulants (DOACs), those treated with aspirin only, and those who received neither OAC or aspirin.

As kidney disease advanced, OAC treatment rates decreased, while aspirin treatment rates increased. The likelihood of treatment with a DOAC dropped significantly in the later stages of kidney disease, while warfarin treatment rates remained relatively stable.

“The main way we can intervene here is to address the overuse of aspirin. There is a misconception that aspirin is safer than OACs and still provides some stroke protection, but we believe there is actually minimal protection against atrial fibrillation related strokes provided by aspirin and that it is not any safer than newer OAC options,” says Sean Pokorney, MD, associate director of the Arrhythmia Core Laboratory at the Duke Clinical Research Institute and part of the research team, in the article.

“The trends we found are concerning because, by overusing aspirin, we are still exposing patients to risk of bleeding without the benefits of stroke prevention from an OAC,” Pokorney adds.

The Duke researchers also found that treatment with DOACs resulted in a lower one-year mortality rate than treatment with warfarin across all stages of kidney disease. In Stages 1 through 3, mortality in the DOAC group was 4.4% compared to 5% in the warfarin group. In patients with stage 4, 5, or end-stage renal disease, there was a mortality rate of 6.3% of those treated with DOACs versus 8.1% of those treated with warfarin.

Pokorney says that providers are appropriately hesitant to prescribe DOACs to patients with end-stage renal disease because of limited data on safety in this patient population, according to the article.

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However, he is working on an ongoing DCRI study, RENAL-AF, that is randomizing hemodialysis patients with atrial fibrillation to either to the DOAC apixaban (Eliquis) or to warfarin. The results of that could provide further evidence for DOAC safety in chronic kidney disease patients, Pokorney says.

Janssen Pharmaceuticals provided funding for the study.