Renal decline in patients with non-valvular atrial fibrillation treated with rivaroxaban or warfarin: A population-based study from the United Kingdom

Antonio González Pérez; Yanina Balabanova; María Eugenia Sáez; Gunnar Brobert; Luis A. Garcı́a Rodrı́guez

doi:10.1016/j.ijcard.2022.01.063

February 2, 2022International Journal of CardiologyOpen Access

Renal decline in patients with non-valvular atrial fibrillation treated with rivaroxaban or warfarin: A population-based study from the United Kingdom

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Why the study?

Reports suggest that renal decline is greater among patients with non-valvular atrial fibrillation treated chronically with warfarin versus some non-vitamin K antagonist oral anticoagulants.

Does rivaroxaban reduce the risk of renal decline compared to warfarin in adults with non-valvular atrial fibrillation?

Structured PICO

Does rivaroxaban reduce the risk of renal decline compared to warfarin in adults with non-valvular atrial fibrillation?

P

Population

11,652 adults with non-valvular atrial fibrillation (NVAF) and preserved renal function (eGFR ≥50 ml/min/1.73m²), excluding those with end-stage renal disease or missing baseline renal labs.

I

Intervention

Rivaroxaban 20 mg/day

C

Comparator

Warfarin

O

Outcome

Doubling serum creatinine (SCr) levels, ≥30% decline in eGFR, and progression to end-stage renal disease (ESRD)surrogate

In patients with non-valvular atrial fibrillation and preserved renal function, rivaroxaban is associated with a significantly lower risk and rate of renal decline compared to warfarin.

Implication

Rivaroxaban was associated with less renal decline than warfarin in NVAF; hypothesis-generating, needs prospective confirmation before practice change.

Abstract

Background Reports suggest that renal decline is greater among patients with non-valvular atrial fibrillation (NVAF) treated chronically with warfarin vs. some non-vitamin K antagonist oral anticoagulants. Methods and results Using primary care electronic health records from the United Kingdom we followed adults with NVAF and who started rivaroxaban (20 mg/day, N = 5338) or warfarin ( N = 6314), excluding those with estimated glomerular filtration rate (eGFR) <50 ml/min/1.73m 2 , end-stage renal disease (ESRD) or no eGFR or serum creatinine (SCr) values recorded in the previous year. Outcomes were: doubling SCr levels, ≥30% decline in eGFR and progression to ESRD. We calculated adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) for each outcome. Average eGFR slope was estimated using mixed model regression. After a mean follow-up 2.5 years, the number of incident cases of adverse renal events within the two cohorts was: doubling SCr ( n = 322), ≥30% decline in eGFR ( n = 1179), and progression to ESRD ( n = 22). Adjusted HRs (95% CIs) for the renal outcomes among rivaroxaban vs. warfarin users were: doubling SCr, 0.63 (0.49–0.81); ≥30% decline in eGFR, 0.76 (0.67–0.86); ESRD, 0.77 (0.29–2.04). Similar results were observed among patients with diabetes or heart failure. Estimated mean decline in renal function over the study period was 2.03 ml/min/1.73 m 2 /year among warfarin users and 1.65 ml/min/1.73 m 2 /year among rivaroxaban users ( p = 0.03). Conclusions We found clear evidence that patients with NVAF, preserved renal function at baseline and treated with rivaroxaban had a markedly reduced risk and rate of renal decline compared with those treated with warfarin.