Department of Pharmacy Practice, University of Connecticut School of Pharmacy, 69 North Eagleville Road, Unit 3092, Storrs, CT 06269, USA.
Evidence-Based Practice Center, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA.
Eur Heart J Qual Care Clin Outcomes. 2020 Oct 1;6(4):301-307. doi: 10.1093/ehjqcco/qcz047.
Vascular calcification is common in diabetic patients. Warfarin has been associated with renovascular calcification and worsening renal function; rivaroxaban may provide renopreservation by decreasing vascular inflammation. We compared the impact of rivaroxaban and warfarin on renal outcomes in diabetic patients with non-valvular atrial fibrillation (NVAF).
Using United States IBM MarketScan data from January 2011 to December 2017, we identified adults with both NVAF and diabetes, newly-initiated on rivaroxaban or warfarin with ≥12-month insurance coverage prior to anticoagulation initiation. Patients with Stage 5 chronic kidney disease (CKD) or undergoing haemodialysis at baseline were excluded. Differences in baseline covariates between cohorts were adjusted using inverse probability-of-treatment weighting (IPTW) based on propensity scores (absolute standardized differences <0.1 achieved for all after adjustment). Outcomes included incidence rates of emergency department/hospital admissions for acute kidney injury (AKI) and the composite of the development of Stage 5 CKD or need for haemodialysis. Patients were followed until an event, index anticoagulant discontinuation/switch, insurance disenrollment, or end-of-data availability. Hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated using Cox regression. We assessed 10 017 rivaroxaban (22.6% received a reduced dose) and 11 665 warfarin users. In comparison to warfarin, rivaroxaban was associated with lower risks of AKI (HR = 0.83, 95% CI = 0.74-0.92) and development of Stage 5 CKD or need for haemodialysis (HR = 0.82, 95% CI = 0.70-0.96). Sensitivity and subgroup analyses had similar effects as the base-case analysis.
Rivaroxaban appears to be associated with lower risks of undesirable renal outcomes vs. warfarin in diabetic NVAF patients.
血管钙化在糖尿病患者中很常见。华法林与肾血管钙化和肾功能恶化有关；利伐沙班可能通过减少血管炎症来提供肾脏保护。我们比较了利伐沙班和华法林对伴有非瓣膜性心房颤动（NVAF）的糖尿病患者的肾脏结局的影响。
我们使用了 2011 年 1 月至 2017 年 12 月期间美国 IBM MarketScan 数据库的数据，纳入了新诊断为 NVAF 且在抗凝治疗开始前至少有 12 个月保险覆盖的糖尿病患者，并开始使用利伐沙班或华法林治疗。排除了基线时患有 5 期慢性肾脏病（CKD）或正在接受血液透析的患者。采用倾向评分（调整后所有变量的绝对标准化差异均<0.1）的逆概率治疗加权法（inverse probability-of-treatment weighting，IPTW）调整两组间的基线协变量差异。主要结局为因急性肾损伤（acute kidney injury，AKI）而急诊/住院的发生率和 5 期 CKD 发展或需要血液透析的复合终点。患者在发生事件（研究药物的停用/转换、保险退保或数据截止）、开始使用研究药物或保险失效前一直处于随访状态。使用 Cox 回归估计风险比（hazard ratio，HR）及其 95%置信区间（confidence interval，CI）。我们评估了 10017 例利伐沙班（22.6%患者使用了较低剂量）和 11665 例华法林使用者。与华法林相比，利伐沙班降低 AKI（HR=0.83，95%CI=0.74-0.92）和 5 期 CKD 发展或需要血液透析（HR=0.82，95%CI=0.70-0.96）的风险较低。敏感性分析和亚组分析的结果与主要分析一致。
与华法林相比，利伐沙班似乎可降低伴有 NVAF 的糖尿病患者不良肾脏结局的风险。
