Use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation across five stages of chronic kidney diseases

Abstract Background Although non-vitamin K antagonist oral anticoagulants (NOACs) were more and more commonly prescribed in the daily practice, data about the use of NOACs in atrial fibrillation (AF) patients with stage 4 and 5 chronic kidney diseases (CKD) are limited. In the present study, we compared the clinical outcomes of AF patients receiving NOACs and those receiving warfarin or non-OACs in different stages of CKD. Methods A total of 39217 AF patients aged >20 years whose data about creatinine clearance (CCr) were available were identified from the electronic health record database of a multi-center healthcare system in Taiwan. Patients were categorized into stage 1 to stage 5 CKDs, and the composite risks of ischemic stroke/systemic embolism, major bleeding and mortality were compared between non-OACs, warfarin and NOACs. Results Around 12.7% and 9.4% of study patients had a stage 4 and stage 5 CKD, respectively. Compared to non-OACs, the use of OACs (either warfarin or NOACs) were consistently associated with a lower risk of composite events from stage 1 to stage 4 CKD, but not for stage 5 CKD (warfarin: aHR 0.912, 95%CI 0.742-1.121; NOACs: aHR 0.993, 95%CI 0.653-1.537)(Figure 1). Compared to warfarin, NOACs were associated with a lower risk of adverse events for patients with stage 2 (aHR 0.630), stage 3 (aHR 0.712) and stage 4 CKD (aHR 0.749). However, the risk did not differ between warfarin and NOACs for stage 1 and stage 5 CKD (Figure 2). Conclusions Although data of the clinical trials for AF patients with stage 4 CKD were relatively lacking, NOACs should still be considered for this AF population. More data are necessary to guide optimal stroke prevention strategy for patients with stage 5 CKD.