Thread by @ISNeducation

1/13 Use of Direct Oral Anticoagulants (DOACs) in Kidney Disease
☑️⬇️ Better bleeding risk profile
☑️No need for monitoring!
☑️Faster action
☑️ less drug & dietary interactions
☑️?⬇️ risk of Vascular calcifications
👉@Kidney_Int
kidney-international.org/article/S0085-…
🧵by @gag_aggarwal

2/ Originally referred to as new/novel/non-VKA oral anticoagulants (NOACs)
the preferred international consensus nomenclature for OACs that directly inhibit 1 molecular target is ->DOAC
Also they are not new anymore🙈been around since early 2000s
ahajournals.org/doi/full/10.11…

3/ Do you use DOACs in patients with GFR<15ml/min/1.73m2 for stroke prevention in AF or VTE?
@ISNkidneycare @arvindcanchi @sibgokcay @FerArceAmare @hswapnil @divyaa24 @AnandhUrmila @Gawad_Nephro @gag_aggarwal @nefrorantes @edgarvlermamd

4/ Yes, I use DOACs in patients with GFR <15ml/min/1.73m2, for
@Nair_Sanj @MayuriTrivedi80 @VijayKher8 @pecoitsfilho @acssjr @RClaure_nefro @BasuNephro @SabineKaram6 @caioqualunque @elliotktannor @myadla @aiakl2001

5/ So can DOACs be safely used for Kidney patients?
❎Renally cleared and protein bound
❎eGFR<25ml/min/1.73m2 excluded from most pivotal DOAC trials
❎DOACs metabolism altered by P-glycoprotein inhibitors/inducers
❎⬇️availability of the reversal agent
👇
onlinelibrary.wiley.com/doi/epdf/10.11…

6/ The simultaneous ⬆️thrombotic & bleeding risk make anticoagulation difficult in Kidney disease population
👉⬆️Risk of AF and VTE
👉⬆️2X risk of VTE in patients with stage 3 or 4 CKD
👉⬆️5X higher risk of intracranial haemorrhage in CKD
Check 👇review
sciencedirect.com/science/articl…

7/ CKD and DOACs
Cochrane review
12,545 patients with CKD (eGFR>30)
across 5 clinical trials
randomized to
DOACs- apixaban, rivaroxaban, edoxaban, or dabigatran
🆚Warfarin
DOACs show
☑️⬇️risk of stroke+systemic embolism; trend👉less major bleeding
cochranelibrary.com/cdsr/doi/10.10…

8/ ARISTOTLE trial
Apixaban🆚Warfarin
Apixaban ->⬇️risk of stroke, mortality & major bleeding

Sub analysis of patients with serial creatinine available
👉 The superior efficacy & safety of apixaban
was similar with normal/poor/worsening renal function
jamanetwork.com/journals/jamac…

9/ DOACs are being used in ESKD, despite being excluded from all pivotal trials

ahajournals.org/doi/full/10.11…
👉Standard-dose Apixaban (5 mg twice/day) was associated with ⬇️risks of stroke/systemic embolism & death
🆚 reduced-dose apixaban (2.5 mg twice/day) or warfarin
VA @NephJC

10/ Except,
What about Apixaban versus No Anticoagulation in ESKD?

This 2020 study in @CJASN 🤔
cjasn.asnjournals.org/content/15/8/1…

->there is no established indication for DOACs use for cardiovascular event prevention in kidney failure, at least at this time.

11/ The VALKYRIE Study

HD Patients randomized to
Vitamin K Antagonists (VKAs) with target INR 2–3,
rivaroxaban 10mg/day, or
rivaroxaban 10mg/day + vitamin K2 2000 µg thrice weekly

All cause death, stroke, and cardiovascular event rates were similar
jasn.asnjournals.org/content/31/1/1…

12/ Impact of DOACs on Kidney functions VS Warfarin

This study
sciencedirect.com/science/articl…
compared 4 oral anticoagulants -apixaban, dabigatran, rivaroxaban & warfarin
for their effects on Renal Outcomes

👉DOACs may be associated with ⬇️ adverse renal outcomes than warfarin

13/ Many unanswered questions remain regarding DOACs in Kidney disease
Whats the right dose ?
Are they safe?
Is one DOAC better than the other in Kidney disease?
How often to measure renal functions?
Should we stop DOACs if GFR falls?
Do we need to measure DOAC levels?