Rhee Tae-Min, Lee So-Ryoung, Choi Eue-Keun, Oh Seil, Lip Gregory Y H
Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea.
Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea.
Front Cardiovasc Med. 2022 Jun 10;9:885548. doi: 10.3389/fcvm.2022.885548. eCollection 2022.
Data on different direct oral anticoagulants (DOACs) in atrial fibrillation (AF) patients with renal impairment are insufficient. We aimed to perform pairwise and network meta-analysis comparing oral anticoagulants (OACs) in AF patients with renal impairment, including advanced chronic kidney disease (CKD) with creatinine clearance <30 mL/min.
PubMed, Embase, Cochrane Database, and references of related articles were searched up to April 2021. We included randomized trials and non-randomized studies using propensity-score or multivariable-model adjustments that compared clinical outcomes among OACs. Hazard ratios (HRs) for stroke or thromboembolism, major bleeding, and all-cause death were pooled using random-effects model.
From 19 studies, 124,628 patients were included. In patients with AF and CKD, DOACs presented significantly lower risks of stroke or thromboembolism [HR = 0.78, 95% confidence interval (CI) = 0.73-0.85, I = 16.6%] and major bleeding [HR = 0.76 (0.64-0.89), I = 85.7%] when compared with warfarin, regardless of the severity of renal impairment. Results were consistent in advanced CKD patients for stroke or thromboembolism [HR = 0.60 (0.43-0.85), I = 0.0%] and major bleeding [HR = 0.74 (0.59-0.93), I = 30.4%]. In the network meta-analysis, edoxaban and apixaban presented the highest rank probability to reduce the risk of stroke or thromboembolism (edoxaban, P-score = 94.5%) and major bleeding (apixaban, P-score = 95.8%), respectively. Apixaban remained the safest OAC with the highest rank probability for major bleeding (P-score = 96.9%) in patients with advanced CKD.
DOACs, particularly apixaban and edoxaban, presented superior efficacy and safety than warfarin in AF patients with CKD. Apixaban was associated with the lowest risk of major bleeding among OACs for patients with advanced CKD.
[PROSPERO], identifier [CRD42021241718].
关于肾功能不全的心房颤动（AF）患者使用不同直接口服抗凝剂（DOACs）的数据不足。我们旨在进行成对和网状荟萃分析，比较肾功能不全的AF患者（包括肌酐清除率<30 mL/min的晚期慢性肾脏病（CKD）患者）使用口服抗凝剂（OACs）的情况。
检索截至2021年4月的PubMed、Embase、Cochrane数据库及相关文章的参考文献。我们纳入了使用倾向评分或多变量模型调整的随机试验和非随机研究，这些研究比较了OACs之间的临床结局。使用随机效应模型汇总卒中或血栓栓塞、大出血和全因死亡的风险比（HRs）。
共纳入19项研究中的124,628例患者。在AF合并CKD的患者中，与华法林相比，DOACs发生卒中或血栓栓塞的风险显著降低[HR = 0.78，95%置信区间（CI）= 0.73 - 0.85，I² = 16.6%]，大出血风险也显著降低[HR = 0.76（0.64 - 0.89），I² = 85.7%]，无论肾功能不全的严重程度如何。在晚期CKD患者中，卒中或血栓栓塞[HR = 0.60（0.43 - 0.85），I² = 0.0%]和大出血[HR = 0.74（0.59 - 0.93），I² = 30.4%]的结果一致。在网状荟萃分析中，依度沙班和阿哌沙班分别在降低卒中或血栓栓塞风险（依度沙班，P评分 = 94.5%）和大出血风险（阿哌沙班，P评分 = 95.8%）方面具有最高的排序概率。在晚期CKD患者中，阿哌沙班仍是最安全的OAC，大出血风险排序概率最高（P评分 = 96.9%）。
在CKD的AF患者中，DOACs，尤其是阿哌沙班和依度沙班，比华法林具有更好的疗效和安全性。在晚期CKD患者中，阿哌沙班是OACs中大出血风险最低的药物。
[PROSPERO]，标识符[CRD42021241718]
