Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN; Division of Nephrology, Hennepin County Medical Center and Department of Medicine, University of Minnesota, Minneapolis, MN.
Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN.
Am J Kidney Dis. 2021 Aug;78(2):180-189. doi: 10.1053/j.ajkd.2020.12.004. Epub 2021 Jan 6.
RATIONALE & OBJECTIVE: Comparing kidney disease progression among patients treated with direct oral anticoagulants (DOACs) versus warfarin has not been well studied. We hypothesized that apixaban would be associated with lower risks of progression of chronic kidney disease (CKD) and progression to incident kidney failure than warfarin in patients with atrial fibrillation (AF).
Retrospective cohort study.
SETTING & PARTICIPANTS: Medicare recipients with stage 3, 4, or 5 CKD and incident AF who received a new prescription for apixaban or warfarin from 2013 through 2017.
Apixaban or warfarin.
Progression to incident kidney failure or, separately, to a more advanced stage of CKD.
Marginal structural cause-specific proportional hazards models with inverse probability weighting to estimate marginal hazard ratios (HRs) for each outcome. HRs compared apixaban to warfarin in intention-to-treat and censored-at-drug-switch analyses.
12,816 individuals met inclusion criteria (50.3% received apixaban; 49.7% received warfarin). After weighting, the mean age of the cohort was 80 ± 7 years, 51% were women, and 88% were White. Approximately 84% had stage 3, 15% had stage 4, and 1% had stage 5 CKD. In the intention-to-treat analysis, apixaban, relative to warfarin, was associated with an HR of developing incident kidney failure of 0.98 (95% confidence interval [CI], 0.79-1.22) and of CKD stage progression of 0.90 (95% CI, 0.82-0.99). Corresponding HRs for censored-at-drug-switch analyses were 0.81 (95% CI, 0.56-1.17) and 0.81 (95% CI, 0.70-0.92). Results were similar for a series of subgroup and sensitivity analyses.
CKD was defined based on diagnosis codes from claims; findings may not be generalizable to non-Medicare CKD populations.
Apixaban, compared with warfarin, was associated with lower risk of CKD stage progression, but not with incident kidney failure.
比较直接口服抗凝剂（DOACs）与华法林治疗患者的肾脏疾病进展情况的研究并不充分。我们假设，在伴有心房颤动（AF）的患者中，与华法林相比，阿哌沙班与慢性肾脏病（CKD）进展和新发肾衰竭的风险降低相关。
回顾性队列研究。
2013 年至 2017 年期间，接受新处方阿哌沙班或华法林的 Medicare 受保人，其 CKD 分期为 3、4 或 5 期，且新发 AF。
阿哌沙班或华法林。
进展为新发肾衰竭或 CKD 更严重阶段。
边缘结构因果特定比例风险模型，采用逆概率加权法估计每个结局的边际风险比（HR）。在意向治疗和药物转换时的删失分析中，将阿哌沙班与华法林进行比较。
共纳入 12816 例符合条件的患者（50.3%接受阿哌沙班；49.7%接受华法林）。经加权后，队列的平均年龄为 80±7 岁，51%为女性，88%为白人。约 84%为 CKD 3 期，15%为 CKD 4 期，1%为 CKD 5 期。在意向治疗分析中，与华法林相比，阿哌沙班发生新发肾衰竭的 HR 为 0.98（95%置信区间[CI]，0.79-1.22），CKD 分期进展的 HR 为 0.90（95%CI，0.82-0.99）。药物转换时的删失分析的相应 HR 为 0.81（95%CI，0.56-1.17）和 0.81（95%CI，0.70-0.92）。一系列亚组和敏感性分析的结果相似。
CKD 是根据索赔中的诊断代码定义的；研究结果可能不适用于非 Medicare CKD 人群。
与华法林相比，阿哌沙班与 CKD 分期进展风险降低相关，但与新发肾衰竭无关。
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