Cardiorenal Outcomes Among Patients With Atrial Fibrillation Treated With Oral Anticoagulants

Rationale & Objective: Direct oral anticoagulants (DOACs) have progressively replaced vitamin K antagonists (VKAs) for stroke prevention in pa-tients with nonvalvular atrial fibrillation (AF). DOACs cause fewer bleeding complications, but their other advantages, particularly related to kid-ney outcomes, remain inconclusive. We studied the risks of chronic kidney disease (CKD) pro-gression and acute kidney injury (AKI) after DOAC and VKA administration for nonvalvular AF.Study Design: Retrospective cohort study. Setting & Participants: Cohort study of Swedish patients enrolled in the Stockholm Creatinine Measurements (SCREAM) project with a diag-nosis of nonvalvular AF during 2011-2018. Exposure: Initiation of DOAC or VKA treatment.Outcome: Primary outcomes were CKD pro-gression (composite of >30% estimated glomer-ular filtration rate [eGFR] decline and kidney failure) and AKI (by diagnosis or KDIGO-defined transient creatinine elevations). Secondary outcomes were death, major bleeding, and the composite of stroke and systemic embolism.Analytical Approach: Propensity score weighted Cox regression was used to balance 50 baseline confounders. Sensitivity analyses included falsification end points, subgroups, and estima-tion of per-protocol effects.Results: We included 32,699 patients (56% initiated DOAC) who were observed for a me-dian of 3.8 years. Their median age was 75 years, 45% were women, and 27% had an eGFR <60 mL/min/1.73 m2. The adjusted HRs for DOAC versus VKA were 0.87 (95% CI, 0.78-0.9 8) for the risk of CKD progression and 0.88 (95% CI, 0.80-0.97) for AKI. HRs were 0.77 (95% CI, 0.67-0.8 9) for major bleeding, 0.93 (95% CI, 0.78-1.11) for the composite of stroke and systemic embolism, and 1.04 (95% CI, 0.95-1.14) for death. The results were similar across subgroups of age, sex, and baseline eGFR when restricting to patients at high risk for thromboembolic events and when censoring follow up at treatment discontinuation or change in type of anticoagulation.Limitations: Missing information on time in ther-apeutic range and treatment dosages.Conclusions: Among patients with nonvalvular AF treated in routine clinical practice compared with VKA use, DOAC use was associated with a lower risk of CKD progression, AKI, and major bleeding but a similar risk of the composite of stroke, systemic embolism, or death.