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Open Access 01-12-2021 | Anticoagulant | Research

Impaired kidney function at ED admission: a comparison of bleeding complications of patients with different oral anticoagulants

Authors: Martin Müller, Michaela Traschitzger, Michael Nagler, Spyridon Arampatzis, Aristomenis K. Exadaktylos, Thomas C. Sauter

Published in: BMC Emergency Medicine | Issue 1/2021

Abstract

Background

Up to a fourth of patients at emergency department (ED) presentation suffer from acute deterioration of renal function, which is an important risk factor for bleeding events in patients on oral anticoagulation therapy. We hypothesized that outcomes of patients, bleeding characteristics, therapy, and outcome differ between direct oral anticoagulants (DOACs) and vitamin-K antagonists (VKAs).

Methods

All anticoagulated patients older than 17 years with an impaired kidney function treated for an acute haemorrhage in a large Swiss university ED from 01.06.2012 to 01.07.2017 were included in this retrospective cohort study. Patient, treatment, and bleeding characteristics as well as outcomes (length of stay ED, intensive care unit and in-hospital admission, ED resource consumption, in-hospital mortality) were compared between patients on DOAC or VKA anticoagulant.

Results

In total, 158 patients on DOAC and 419 patients on VKA with acute bleeding and impaired renal function were included. The renal function in patients on VKA was significantly worse compared to patients on DOAC (VKA: median 141 μmol/L vs. DOAC 132 μmol/L, p = 0.002). Patients on DOAC presented with a smaller number of intracranial bleeding compared to VKA (14.6% DOAC vs. 22.4% VKA, p = 0.036). DOAC patients needed more emergency endoscopies (15.8% DOAC vs, 9.1% VKA, p = 0.020) but less interventional emergency therapies to stop the bleeding (13.9% DOAC vs. 22.2% VKA, p = 0.027). Investigated outcomes did not differ significantly between the two groups.

Conclusions

DOAC patients were found to have a smaller proportional incidence of intracranial bleedings, needed more emergency endoscopies but less often interventional therapy compared to patients on VKA. Adapted treatment algorithms are a potential target to improve care in patients with DOAC.

Landefeld CS, Beyth RJ. Anticoagulant-related bleeding: clinical epidemiology, prediction, and prevention. Am J Med. 1993;95(3):315–28. https://doi.org/10.1016/0002-9343(93)90285-W.CrossRefPubMed

Sauter TC, Amylidi A-L, Ricklin ME, Lehmann B, Exadaktylos AK. Direct new oral anticoagulants in the emergency department: experience in everyday clinical practice at a Swiss university hospital. Eur J Intern Med. April 2016;29:e13–5. https://doi.org/10.1016/j.ejim.2015.12.009.CrossRefPubMed

Ruff CT, Giugliano RP, Braunwald E, Hoffman EB, Deenadayalu N, Ezekowitz MD. u. a. comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. März 2014;383(9921):955–62. https://doi.org/10.1016/S0140-6736(13)62343-0.CrossRefPubMed

Raccah BH, Perlman A, Danenberg HD, Pollak A, Muszkat M, Matok I. Major bleeding and hemorrhagic stroke with direct Oral anticoagulants in patients with renal failure. Chest. Juni 2016;149(6):1516–24. https://doi.org/10.1016/j.chest.2015.12.029.CrossRefPubMed

Cheung K-S, Leung WK. Gastrointestinal bleeding in patients on novel oral anticoagulants: risk, prevention and management. World J Gastroenterol. 2017;23(11):1954–63. https://doi.org/10.3748/wjg.v23.i11.1954.CrossRefPubMedPubMedCentral

Di Lullo L, Ronco C, Cozzolino M, Russo D, Russo L, Di Iorio B, u. a. Nonvitamin K-dependent oral anticoagulants (NOACs) in chronic kidney disease patients with atrial fibrillation. Thromb Res. Juli 2017;155:38–47.

Steffel J, Verhamme P, Potpara TS, Albaladejo P, Antz M, Desteghe L. u. a. the 2018 European heart rhythm association practical guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur heart J. 21. April. 2018;39(16):1330–93.

Reinecke H, Brand E, Mesters R, Schäbitz W-R, Fisher M, Pavenstädt H. u. a. dilemmas in the Management of Atrial Fibrillation in chronic kidney disease. J Am Soc Nephrol. April 2009;20(4):705–11. https://doi.org/10.1681/ASN.2007111207.CrossRefPubMed

Khan F, Huang H, Datta YH. Direct oral anticoagulant use and the incidence of bleeding in the very elderly with atrial fibrillation. J Thromb Thrombolysis. November 2016;42(4):573–8. https://doi.org/10.1007/s11239-016-1410-z.CrossRefPubMedPubMedCentral

10.

Shin J-I, Secora A, Alexander GC, Inker LA, Coresh J, Chang AR. u. a. risks and benefits of direct Oral anticoagulants across the Spectrum of GFR among incident and prevalent patients with atrial fibrillation. Clin J am Soc Nephrol. 7. August. 2018;13(8):1144–52.

11.

Heidbuchel H, Verhamme P, Alings M, Antz M, Diener H-C, Hacke W, u. a. Updated European Heart Rhythm Association practical guide on the use of non-vitamin-K antagonist anticoagulants in patients with non-valvular atrial fibrillation: Executive summary. Eur Heart J. 9. Juni 2016;ehw058.

12.

Challiner R, Ritchie JP, Fullwood C, Loughnan P, Hutchison AJ. Incidence and consequence of acute kidney injury in unselected emergency admissions to a large acute UK hospital trust. BMC Nephrol [internet]. Dezember 2014 [zitiert 2. August 2019];15(1). Verfügbar unter. 2014. https://bmcnephrol.biomedcentral.com/articles/10.1186/1471-2369-15-84.

13.

Sherman RE, Anderson SA, Pan GJD, Gray GW, Gross T, Hunter NL. u. a. real-world evidence - what is it and what can it tell us? N Engl J med. 8. Dezember. 2016;375(23):2293–7.

14.

Corrigan-Curay J, Sacks L, Woodcock J. Real-world evidence and real-world data for evaluating drug safety and effectiveness. JAMA. 4. September. 2018;320(9):867–8.

15.

Levey AS, de Jong PE, Coresh J, Nahas ME. L., Astor BC, Matsushita K, u. a. the definition, classification, and prognosis of chronic kidney disease: a KDIGO controversies conference report. Kidney Int. Juli 2011;80(1):17–28. https://doi.org/10.1038/ki.2010.483.CrossRefPubMed

16.

Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF, Feldman HI. u. a. a new equation to estimate glomerular filtration rate. Ann intern med. 5. Mai. 2009;150(9):604–12.

17.

Monégat M, Sermet C, Perronnin M, Rococo E. Polypharmacy: definitions, measurement and stakes involved. Rev Lit Meas Tests. 2014.

18.

Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83. https://doi.org/10.1016/0021-9681(87)90171-8.CrossRef

19.

Schulman S, Kearon C. Subcommittee on control of anticoagulation of the scientific and standardization Committee of the International Society on thrombosis and Haemostasis. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients. J Thromb Haemost JTH. April 2005;3(4):692–4. https://doi.org/10.1111/j.1538-7836.2005.01204.x.CrossRefPubMed

20.

Rutschmann OT, Hugli OW, Marti C, Grosgurin O, Geissbuhler A, Kossovsky M, u. a. Reliability of the revised Swiss Emergency Triage Scale: a computer simulation study. Eur J Emerg Med Off J Eur Soc Emerg Med. 14. Februar 2017;

21.

Lutz J, Jurk K, Schinzel H. Direct oral anticoagulants in patients with chronic kidney disease: patient selection and special considerations. Int J Nephrol Renov Dis. 12. Juni 2017;10:135–43. https://doi.org/10.2147/IJNRD.S105771.CrossRef

22.

Mega J, Braunwald E, Mohanavelu S, Burton P, Poulter R, Misselwitz F. u. a. rivaroxaban versus placebo in patients with acute coronary syndromes (ATLAS ACS-TIMI 46): a randomised, double-blind, phase II trial. Lancet. Juli 2009;374(9683):29–38. https://doi.org/10.1016/S0140-6736(09)60738-8.CrossRefPubMed

23.

Rothberg MB, Celestin C, Fiore LD, Lawler E, Cook JR. Warfarin plus Aspirin after Myocardial Infarction or the Acute Coronary Syndrome: Meta-Analysis with Estimates of Risk and Benefit. Ann Intern Med. 16. August 2005;143(4):241.

24.

Abraham NS, Noseworthy PA, Yao X, Sangaralingham LR, Shah ND. Gastrointestinal Safety of Direct Oral Anticoagulants: A Large Population-Based Study. Gastroenterology. 1. April 2017;152(5):1014–1022.e1.

25.

Shaw JR, Castellucci L, Siegal D, Stiell I, Syed S, Lampron J, u. a. Management of direct oral anticoagulant associated bleeding: Results of a multinational survey. Thromb Res. März 2018;163:19–21.

26.

Müller M, Eastline J, Nagler M, Exadaktylos AK, Sauter TC. Application of prothrombin complex concentrate for reversal of direct oral anticoagulants in clinical practice: indications, patient characteristics and clinical outcomes compared to reversal of vitamin K antagonists. Scand J Trauma Resusc Emerg Med. 2019;27(1):48. https://doi.org/10.1186/s13049-019-0625-3.CrossRefPubMedPubMedCentral

27.

Luo C, Chen F, Chen Y-H, Zhao C-F, Feng C-Z, Liu H-X. u. a. prothrombin complex concentrates and andexanet for management of direct factor Xa inhibitor related bleeding: a meta-analysis. Eur Rev Med Pharmacol Sci. März 2021;25(6):2637–53. https://doi.org/10.26355/eurrev_202103_25428.CrossRefPubMed

28.

Desai J, Kolb J, Weitz J, Aisenberg J. Gastrointestinal bleeding with the new oral anticoagulants – defining the issues and the management strategies. Thromb Haemost. 2013;110(08):205–12. https://doi.org/10.1160/TH13-02-0150.CrossRefPubMed

29.

Moner-Banet T, Alberio L, Bart P-A. Does one dose really fit all? On the monitoring of direct Oral anticoagulants: a review of the literature. Hamostaseologie. Juni 2020;40(2):184–200. https://doi.org/10.1055/a-1113-0655.CrossRefPubMed

30.

Ilgen JS, Humbert AJ, Kuhn G, Hansen ML, Norman GR, Eva KW. u. a. assessing diagnostic reasoning: a consensus statement summarizing theory, practice, and future needs. Acad Emerg Med Off J Soc Acad Emerg Med. Dezember 2012;19(12):1454–61. https://doi.org/10.1111/acem.12034.CrossRef

31.

Kämmer JE, Hautz WE, Herzog SM, Kunina-Habenicht O, Kurvers RHJM. The Potential of Collective Intelligence in Emergency Medicine: Pooling Medical Students’ Independent Decisions Improves Diagnostic Performance. Med Decis Making. 29. März 2017;0272989X1769699.

32.

Hautz WE, Kämmer JE, Hautz SC, Sauter TC, Zwaan L, Exadaktylos AK, u. a. Diagnostic error increases mortality and length of hospital stay in patients presenting through the emergency room. Scand J Trauma Resusc Emerg Med. 8. Mai 2019;27(1):54.

Title: Impaired kidney function at ED admission: a comparison of bleeding complications of patients with different oral anticoagulants
Authors: Martin Müller
Michaela Traschitzger
Michael Nagler
Spyridon Arampatzis
Aristomenis K. Exadaktylos
Thomas C. Sauter
Publication date: 01-12-2021
Publisher: BioMed Central
Keywords: Anticoagulant
Direct Oral Anticoagulant
Direct Oral Anticoagulant
Gastrointestinal Bleeding
Published in: BMC Emergency Medicine / Issue 1/2021
Electronic ISSN: 1471-227X
DOI: https://doi.org/10.1186/s12873-021-00497-1

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Impaired kidney function at ED admission: a comparison of bleeding complications of patients with different oral anticoagulants

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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