Ahuja Tania, Sessa Kelly, Merchan Cristian, Papadopoulos John, Green David
Medicine, Cardiology & Anticoaguation, NYU Langone Health-Department of Pharmacy, 550 First Avenue, New York, NY 10016, USA.
NYU Langone Health-Department of Pharmacy, 550 First Avenue, New York, NY 10016, USA.
Adv Hematol. 2021 Jan 29;2021:8870015. doi: 10.1155/2021/8870015. eCollection 2021.
Warfarin remains the preferred oral anticoagulant for the treatment of venous thromboembolism (VTE) in patients with advanced chronic kidney disease (CKD). Although the direct oral anticoagulants (DOACs) have become preferred for treatment of VTE in the general population, patients with advanced CKD were excluded from the landmark trials. Postmarketing, safety data have demonstrated oral factor Xa inhibitors (OFXais) such as apixaban and rivaroxaban to be alternatives to warfarin for the prevention of stroke and systemic embolism in patients with atrial fibrillation. However, it remains unknown if these safety data can be extrapolated to the treatment of VTE and CKD.
A retrospective cohort study from January 2013 to October 2019 was performed at NYU Langone Health. All adult patients with CKD stage 4 or greater, treated with anticoagulation for VTE, were screened. The primary outcome was tolerability of anticoagulant therapy at 3 months, defined as a composite of bleeding, thromboembolic events, and/or discontinuation rates. The secondary outcomes included bleeding, discontinuations, and recurrent thromboembolism.
There were 56 patients evaluated, of which 39 (70%) received warfarin and 17 (30%) received an OFXai (apixaban or rivaroxaban). Tolerability at 3 months was assessed in 48/56 patients (86%). A total of 34/48 (71%) patients tolerated anticoagulation at 3 months, 12 (80%) in the OFXai arm, and 22 (67%) in the warfarin arm (=0.498). There were 10/48 (21%) patients that experienced any bleeding events within 3 months, 7 on warfarin, and 3 on apixaban. Recurrence of thromboembolism within 3 months occurred in 3 patients on warfarin, with no recurrence in the OFXai arm. . OFXais were better tolerated compared to warfarin for the treatment of VTE in CKD, with lower rates of bleeding, discontinuations, and recurrent thromboembolism in a small cohort. Future prospective studies are necessary to confirm these findings.
华法林仍然是晚期慢性肾脏病（CKD）患者静脉血栓栓塞症（VTE）治疗的首选口服抗凝剂。尽管直接口服抗凝剂（DOACs）已成为普通人群VTE治疗的首选，但晚期CKD患者被排除在具有里程碑意义的试验之外。上市后，安全性数据表明，阿哌沙班和利伐沙班等口服Xa因子抑制剂（OFXais）可作为华法林的替代药物，用于预防心房颤动患者的中风和全身性栓塞。然而，这些安全性数据是否能外推至VTE和CKD的治疗仍不清楚。
在纽约大学朗格尼健康中心进行了一项从2013年1月至2019年10月的回顾性队列研究。筛选了所有接受抗凝治疗VTE的4期及以上CKD成年患者。主要结局是3个月时抗凝治疗的耐受性，定义为出血、血栓栓塞事件和/或停药率的综合指标。次要结局包括出血、停药和复发性血栓栓塞。
共评估了56例患者，其中39例（70%）接受华法林治疗，17例（30%）接受OFXai（阿哌沙班或利伐沙班）治疗。48/56例患者（86%）评估了3个月时的耐受性。共有34/48例（71%）患者在3个月时耐受抗凝治疗，OFXai组12例（80%），华法林组22例（67%）（P=0.498）。48例中有10例（21%）患者在3个月内发生任何出血事件，华法林组7例，阿哌沙班组3例。华法林组3例患者在3个月内发生血栓栓塞复发，OFXai组无复发。在CKD患者VTE治疗中，OFXais比华法林耐受性更好，在一个小队列中出血、停药和复发性血栓栓塞发生率更低。未来有必要进行前瞻性研究以证实这些发现。
