Dataset Information

The association between kidney function and major bleeding in older adults with atrial fibrillation starting warfarin treatment: population based observational study.

ABSTRACT:

Objective

To determine rates of major bleeding by level of kidney function for older adults with atrial fibrillation starting warfarin.

Design

Retrospective cohort study.

Setting

Community based, using province wide laboratory and administrative data in Alberta, Canada.

Participants

12,403 adults aged 66 years or more, with atrial fibrillation who started warfarin treatment between 1 May 2003 and 31 March 2010 and had a measure of kidney function at baseline. Kidney function was estimated using the Chronic Kidney Disease Epidemiology Collaboration equation and participants were categorised based on estimated glomerular filtration rate (eGFR): ? 90, 60-89, 45-59, 30-44, 15-29, <15 mL/min/1.73 m(2). We excluded participants with end stage renal disease (dialysis or renal transplant) at baseline.

Main outcome measures

Admission to hospital or visit to an emergency department for major bleeding (intracranial, upper and lower gastrointestinal, or other).

Results

Of 12,403 participants, 45% had an eGFR <60 mL/min/1.73 m(2). Overall, 1443 (11.6%) experienced a major bleeding episode over a median follow-up of 2.1 (interquartile range: 1.0-3.8) years. During the first 30 days of warfarin treatment, unadjusted and adjusted rates of major bleeding were higher at lower eGFR (P for trend <0.001 and 0.001, respectively). Adjusted bleeding rates per 100 person years were 63.4 (95% confidence interval 24.9 to 161.6) in participants with eGFR <15 mL/min/1.73 m(2) compared with 6.1 (1.9 to 19.4) among those with eGFR >90 mL/min/1.73 m(2) (adjusted incidence rate ratio 10.3, 95% confidence interval 2.3 to 45.5). Similar associations were observed at more than 30 days after starting warfarin, although the magnitude of the increase in rates across eGFR categories was attenuated. Across all eGFR categories, adjusted rates of major bleeding were consistently higher during the first 30 days of warfarin treatment compared with the remainder of follow-up. Increases in major bleeding rates were largely due to gastrointestinal bleeding (3.5-fold greater in eGFR <15 mL/min/1.73 m(2) compared with ? 90 mL/min/1.73 m(2)). Intracranial bleeding was not increased with worsening kidney function.

Conclusions

Reduced kidney function was associated with an increased risk of major bleeding among older adults with atrial fibrillation starting warfarin; excess risks from reduced eGFR were most pronounced during the first 30 days of treatment. Our results support the need for careful consideration of the bleeding risk relative to kidney function when assessing the risk-benefit ratio of warfarin treatment in people with chronic kidney disease and atrial fibrillation, particularly in the first 30 days of treatment.

SUBMITTER: Jun M

PROVIDER: S-EPMC6169066 | biostudies-literature | 2015 Feb

REPOSITORIES: biostudies-literature

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Publications

The association between kidney function and major bleeding in older adults with atrial fibrillation starting warfarin treatment: population based observational study.

Jun Min M James Matthew T MT Manns Braden J BJ Quinn Robert R RR Ravani Pietro P Tonelli Marcello M Perkovic Vlado V Winkelmayer Wolfgang C WC Ma Zhihai Z Hemmelgarn Brenda R BR

BMJ (Clinical research ed.) 20150203

<h4>Objective</h4>To determine rates of major bleeding by level of kidney function for older adults with atrial fibrillation starting warfarin.<h4>Design</h4>Retrospective cohort study.<h4>Setting</h4>Community based, using province wide laboratory and administrative data in Alberta, Canada.<h4>Participants</h4>12,403 adults aged 66 years or more, with atrial fibrillation who started warfarin treatment between 1 May 2003 and 31 March 2010 and had a measure of kidney function at baseline. Kidney ...[more]

PMID: 25647223

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Project description:BackgroundLimited data are available about the real-world safety of non-vitamin K antagonist oral anticoagulants (NOACs).ObjectivesTo compare the major bleeding risk among newly anticoagulated non-valvular atrial fibrillation (NVAF) patients initiating apixaban, warfarin, dabigatran or rivaroxaban in the United States.Methods and resultsA retrospective cohort study was conducted to compare the major bleeding risk among newly anticoagulated NVAF patients initiating warfarin, apixaban, dabigatran or rivaroxaban. The study used the Truven MarketScan(®) Commercial & Medicare supplemental US database from 1 January 2013 through 31 December 2013. Major bleeding was defined as bleeding requiring hospitalisation. Cox model estimated hazard ratios (HRs) of major bleeding were adjusted for age, gender, baseline comorbidities and co-medications. Among 29 338 newly anticoagulated NVAF patients, 2402 (8.19%) were on apixaban; 4173 (14.22%) on dabigatran; 10 050 (34.26%) on rivaroxaban; and 12 713 (43.33%) on warfarin. After adjusting for baseline characteristics, initiation on warfarin [adjusted HR (aHR): 1.93, 95% confidence interval (CI): 1.12-3.33, P=.018] or rivaroxaban (aHR: 2.19, 95% CI: 1.26-3.79, P=.005) had significantly greater risk of major bleeding vs apixaban. Dabigatran initiation (aHR: 1.71, 95% CI: 0.94-3.10, P=.079) had a non-significant major bleeding risk vs apixaban. When compared with warfarin, apixaban (aHR: 0.52, 95% CI: 0.30-0.89, P=.018) had significantly lower major bleeding risk. Patients initiating rivaroxaban (aHR: 1.13, 95% CI: 0.91-1.41, P=.262) or dabigatran (aHR: 0.88, 95% CI: 0.64-1.21, P=.446) had a non-significant major bleeding risk vs warfarin.ConclusionAmong newly anticoagulated NVAF patients in the real-world setting, initiation with rivaroxaban or warfarin was associated with a significantly greater risk of major bleeding compared with initiation on apixaban. When compared with warfarin, initiation with apixaban was associated with significantly lower risk of major bleeding. Additional observational studies are required to confirm these findings.

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Dataset Information

The association between kidney function and major bleeding in older adults with atrial fibrillation starting warfarin treatment: population based observational study.

Objective

Design

Setting

Participants

Main outcome measures

Results

Conclusions

Publications

The association between kidney function and major bleeding in older adults with atrial fibrillation starting warfarin treatment: population based observational study.

Similar Datasets

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