Kidney Week

Abstract: FR-OR26

Effectiveness and Safety of Apixaban Initiation following Newly Diagnosed Atrial Fibrillation in Patients with Kidney Failure on Hemodialysis

Session Information

• Dialysis: What's New in Techniques and Management
  October 25, 2024 | Location: Room 8, Convention Center
  Abstract Time: 05:40 PM - 05:50 PM

Category: Dialysis

• 801 Dialysis: Hemodialysis and Frequent Dialysis

Authors

• Winkelmayer, Wolfgang C., Baylor College of Medicine Margaret M and Albert B Alkek Department of Medicine, Houston, Texas, United States

Wolfgang C. Winkelmayer, MD, ScD, MPH, FASN

• Chang, Tara I., Stanford University School of Medicine, Stanford, California, United States

Tara I. Chang, MD, MS, FASN

• Erickson, Kevin F., Baylor College of Medicine Margaret M and Albert B Alkek Department of Medicine, Houston, Texas, United States

Kevin F. Erickson, MD, MS, FASN

• Niu, Jingbo, Baylor College of Medicine Margaret M and Albert B Alkek Department of Medicine, Houston, Texas, United States

Jingbo Niu, MD, PhD

Background

Atrial fibrillation (AF) is common in the kidney failure population. While recent guidelines deem it “reasonable to prescribe […] apixaban for oral anticoagulation to reduce the risk of stroke” in patients on dialysis, the data supporting this recommendation are limited.

Methods

We used the USRDS to retrospectively identify adult, Medicare-insured patients on hemodialysis who were newly-diagnosed with AF between 2014 and 2019 and who had not received any oral anticoagulant (OAC) prior to AF. Using propensity score methods integrating baseline demographics, comorbidities, cardiovascular medication use, and CROWNWEB clinical data we compared patients who, within 30 days after the index AF diagnosis, were newly initiated on apixaban to otherwise similar patients who were not initiated on any OAC. We compared the groups in their time to ischemic stroke, systemic thromboembolism, hemorrhagic stroke, clinically meaningful bleeding, and death. We conducted as-treated and per-protocol analyses and estimated cause-specific hazard ratios (HR) for death or sub-distribution HR for all other outcomes.

Results

Of 75,269 patients newly-diagnosed with AF, who were previously OAC-naïve, 4283 initiated apixaban, whereas 63,806 did not initiate any OAC within 30 days. Propensity matching 3985 apixaban users with 3985 OAC non-users balanced all measured baseline characteristics. Apixaban was initiated a median 5 (IQR: 2-12) days after AF. Users were mean age 68 yrs, 46% female, 63% of white and 30% of Black race, and 16% Hispanic. Median CHA₂DS₂-VASc score was 4 (IQR: 3-5). Median duration of apixaban use was 69 (IQR: 42-171) days. The rate of ischemic stroke was 46% lower (HR=0.54; 95%CI, 0.40–0.72) and that of systemic thromboembolism was 34% lower (HR=0.66; 95%CI, 0.53-0.83) in apixaban users. While there was no difference in hemorrhagic stroke (HR=0.94; 95%CI, 0.58-1.53), apixaban users had higher rates of clinically important bleeding (HR=1.20; 95%CI, 1.08-1.33) than OAC non-users. The HR for mortality was 0.39 (95%CI, 0.33-0.44) in as-treated and 0.61 (95%CI, 0.56-0.67) in per-protocol analyses.

Conclusion

Initiation of apixaban soon after newly-diagnnosed AF was associated with lower risk of ischemic stroke and systemic thromboembolism, but at the expense of higher rates of clinically meaningful bleeding.

Funding

• NIDDK Support