Winkelmayer Wolfgang C, Hu Austin, Khairallah Pascale, Airy Medha, Erickson Kevin F, Chang Tara I, Niu Jingbo
Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX.
Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA.
Kidney Med. 2024 Nov 9;7(2):100926. doi: 10.1016/j.xkme.2024.100926. eCollection 2025 Feb.
RATIONALE & OBJECTIVE: Atrial fibrillation (AF) is common in patients with kidney failure on hemodialysis (HD), but few patients receive oral anticoagulant (OAC) treatment. Availability of direct-target OACs starting in 2010 may have induced greater OAC initiation, but this has not been systematically studied.
Retrospective cohort study.
SETTING & PARTICIPANTS: Using Medicare fee-for-service billing claims (2006-2020), we identified previously OAC-naïve HD patients newly-diagnosed with AF between January 1, 2007, and October 1, 2020.
Calendar year; race/ethnicity.
OAC initiation within 90 days from AF diagnosis (any; specific agent).
We estimated initiation risk ratios for each calendar year compared with the referent cohort, 2007, using unadjusted and multivariable-adjusted modified Poisson regression. We also determined differences by racial/ethnic group in OAC initiation, as well as any changes in these disparities over time.
Among 82,389 HD patients newly-diagnosed with AF, 20,002 (24.3%) initiated new OAC treatment within 90 days: 20.5% in 2007 and 34.1% in 2020. Direct-target OACs accounted for 81.0% of OAC initiations in 2020. Adjusted regression models estimated that OAC initiation remained essentially unchanged between 2007 and 2013, but thereafter increased toward a demographics-adjusted risk ratio of 1.61 (95% CI: 1.50-1.73) in 2020. Compared with non-Hispanic Whites, the rates of OAC initiation were 15% (95% CI, 12%-17%) lower among Black patients, 29% (95% CI, 24%-34%) lower among Asian patients, and 22% (95% CI, 19%-25%) lower among Hispanic patients. These disparities were not found to have differed across time ( = 0.75).
Lack of clinical detail to firmly establish contraindications to OAC initiation.
While rates of OAC initiation among patients on HD with newly-diagnosed AF increased in recent years, predominantly driven by increased use of apixaban, OAC initiation rates remained low, at 34% of patients in 2020. Compared with non-Hispanic White patients, OAC initiation remained consistently lower in patients of other race and ethnic groups.
心房颤动（AF）在接受血液透析（HD）的肾衰竭患者中很常见，但很少有患者接受口服抗凝剂（OAC）治疗。2010年开始有直接靶向OAC可用，这可能促使更多患者开始使用OAC，但尚未进行系统研究。
回顾性队列研究。
利用医疗保险按服务收费的账单索赔数据（2006 - 2020年），我们确定了2007年1月1日至2020年10月1日期间新诊断为AF且此前未使用过OAC的HD患者。
日历年；种族/族裔。
AF诊断后90天内开始使用OAC（任何；特定药物）。
我们使用未调整和多变量调整的修正泊松回归，估计每个日历年与参照队列2007年相比的起始风险比。我们还确定了不同种族/族裔群体在开始使用OAC方面的差异，以及这些差异随时间的任何变化。
在82389例新诊断为AF的HD患者中，20002例（24.3%）在90天内开始新的OAC治疗：2007年为20.5%，2020年为34.1%。2020年直接靶向OAC占OAC起始治疗的81.0%。调整后的回归模型估计，2007年至2013年期间OAC起始率基本保持不变，但此后上升，到2020年人口统计学调整后的风险比为1.61（95%CI：1.50 - 1.73）。与非西班牙裔白人相比，黑人患者的OAC起始率低15%（95%CI，12% - 17%），亚洲患者低29%（95%CI，24% - 34%），西班牙裔患者低22%（95%CI，19% - 25%）。未发现这些差异随时间有所不同（P = 0.75）。
缺乏确定OAC起始治疗禁忌证的临床细节。
虽然近年来新诊断为AF的HD患者中OAC起始率有所增加，主要是由于阿哌沙班使用增加，但OAC起始率仍然较低，2020年为34%的患者。与非西班牙裔白人患者相比，其他种族和族裔群体的患者OAC起始率一直较低。
