Oral anticoagulation in patients with atrial fibrillation and stage IV and V chronic kidney disease: a systematic review and meta-analysis
Notice bibliographique
Résumé
Abstract Introduction The association between atrial fibrillation (AF) and chronic kidney disease (CKD) is directly proportional and carries a higher risk of death, bleeding, and thromboembolism (TE). There is uncertainty on the clinical benefit of direct oral anticoagulants (DOAC) in patients with advanced stages of CKD. Purpose To perform a systematic review and meta-analysis of the available literature on the efficacy and safety of DOAC compared to warfarin in patients with AF and stage IV and V CKD with or without hemodialysis. Methods We reviewed PubMed, SCOPUS, EMBASE, LILACS, Google Scholar, Open Gray, and Clinical Trials until April 30th, 2021. A standardized search was performed independently by 2 authors. The primary efficacy endpoint was the reduction of TE (stroke or systemic embolism). The primary safety outcome was major bleeding, additional bleeding outcomes were analyzed as well. We included randomized controlled trials and observational intervention studies. Results We analyzed data from 80,771 patients participating in 14 studies (2 sub-analyses of randomized controlled trials and 12 observational studies). The risk of bias was low, moderate, and high in 2, 6, and 6 studies, respectively. We did not find any difference between the use of DOAC versus warfarin to reduce the risk of TE; there was a trend but non statistically significant though (RR: 0.88 [95% CI, 0.72–1.06], I2=18.7%). Apixaban showed similar behaviour in the reduction of TE with low heterogeneity (RR: 0.86 [95% CI, 0.68–1.08], I2=0%). Conversely, dabigatran (RR: 0.73 [95% CI, 0.37–1.42], I2=17%) and rivaroxaban (RR: 1.08 [95% CI, 0.62–1.89], I2=49%) showed neutral distribution and had higher heterogeneity (Figure 1). The risk of major bleeding was not reduced significantly by DOAC compared to warfarin (RR: 0.9 [95% CI, 0.67–1.21], I2=80.6%), apixaban showed a trend to have a lower risk of major bleeding, but it was not statistically significant (RR: 0.7 [95% CI, 0.46–1.08], I2=53.3%). Rivaroxaban expressed neutral outcome (RR: 0.94 [95% CI, 0.66–1.35], I2=68.3%), and dabigatran had a clear inclination to increase major bleeding (RR: 1.42 [95% CI, 0.99–2.04], I2=6.6%) (Figure 2). Dabigatran significantly increased the risk of gastrointestinal bleeding in our studied population (RR: 1.49 [95% CI, 1.08–2.05]), although this conclusion was obtained from one study. Conclusion The use of DOAC compared to warfarin in patients with AF and stage IV and V CKD did not significantly reduce the rate of TE. There was a trend to reduce this outcome with apixaban, but it did not reach significance due to the inclusion in our study of patients in hemodialysis that represent a higher risk subgroup of patients. Major bleeding showed a similar pattern, expressing a non-statistically significant trend to be reduced in the DOAC group, especially with apixaban. Dabigatran increased the risk of bleeding by 49% in the studied population. Funding Acknowledgement Type of funding sources: None.
Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.
Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,012 | 0,028 |
| Méta-épidémiologie (sens strict) | 0,002 | 0,001 |
| Méta-épidémiologie (sens large) | 0,020 | 0,029 |
| Bibliométrie | 0,006 | 0,007 |
| Études des sciences et des technologies | 0,001 | 0,001 |
| Communication savante | 0,003 | 0,002 |
| Science ouverte | 0,002 | 0,001 |
| Intégrité de la recherche | 0,002 | 0,001 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,003 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».