Risk of Bleeding, Thrombosis and Death among Atrial Fibrillation Patients Treated with Oral Anticoagulants Across Estimated Glomerular Filtration Rates

Abstract

There are limited data about the clinical benefits and harm of oral anticoagulants (OACs) for stroke prevention in patients with atrial fibrillation (AF) and chronic kidney disease using CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) creatinine equation for glomerular filtration rate (GFR) estimation in nuanced GFR stratification. We conducted a retrospective study in 12 centers in China and included 9,510 patients with AF. We grouped patients into the following estimated GFR (eGFR) categories: ≥60 (n = 7,616), 45 to 59 (n = 1,139), 30 to 44 (n = 474), and <30 (n = 281) ml/min/1.73 m². Logistic regression was used to the compare risks of major bleeding, minor bleeding, total bleeding, thrombosis, and all-cause deaths in patients with AF with eGFR 45 to 59, 30 to 44, <30 ml/min/1.73 m², and ≥60 ml/min/1.73 m² after taking OACs. Patients with AF treated with OACs with eGFR 45 to 59, 30 to 44, and <30 ml/min/1.73 m² had a significantly increased risk of all-cause deaths compared with eGFR ≥60 ml/min/1.73 m² (adjusted odds ratio [aOR] 1.326, 95% confidence interval [CI] 1.049 to 1.665, p = 0.016; aOR 1.634, 95% CI 1.197 to 2.200, p = 0.002; aOR 2.492, 95% CI 1.766 to 3.471, p <0.001; respectively). Higher eGFR was associated with a significantly lower risk of all-cause deaths (aOR 0.990, 95% CI 0.986 to 0.994, p <0.001) and major bleeding (aOR 0.988, 95% CI 0.979 to 0.998, p = 0.018). Direct OACs remarkably reduced risk of major bleeding in those with eGFR 30 to 44 ml/min/1.73 m² compared with warfarin. In conclusion, in patients with AF treated with OACs, patients with eGFR 45 to 59, 30 to 44, and <30 ml/min/1.73 m² had a significantly increased risk of all-cause deaths compared with eGFR ≥60 ml/min/1.73 m², and the risk of all-cause deaths increased with decreasing eGFR. Direct OACs are at least safe alternatives to warfarin in patients with AF with eGFR 30 to 44 ml/min/1.73 m².