"There is plenty of room to improve the outcomes of VTE patients with CKD," Dr. Shinya Goto of Tokai University School of Medicine in Kanagawa told Reuters Health by email. He highlighted that "patients with moderate/severe CKD patients are less likely to be treated with direct-acting oral anticoagulants (DOACs), but noted that "appropriate dosing of DOACs in CKD patients is difficult because the drugs are excreted, at least in part, by the kidney."
As reported in JAMA Network Open, Dr. Goto and colleagues studied outcomes of close to 9,000 VTE patients (median age, 57; 49% women; 77% White). Overall, 2,055 (23%; median age, 70) had moderate-to-severe CKD.
Fifty-seven percent of those with moderate-to-severe CKD and 59% with mild or no CKD presented with deep vein thrombosis (DVT) alone; 27% versus 25% presented with pulmonary embolism (PE) alone; and 16.4% versus 16.2%, presented with both PE and DVT.
Patients with moderate-to-severe CKD were more likely to be female (57% vs. 47%) and over age 65 (33% vs. 62.2%). At baseline, receipt of parenteral therapy alone was comparable between the groups (17% vs. 18%).
As Dr. Goto noted, those with more severe disease were less likely to be receiving DOACs, either alone (27% vs. 31%) or in combination with parenteral therapy (16% vs. 18%).
Also as noted, those with moderate-to-severe CKD had a higher risk of all-cause mortality (adjusted hazard ratio, 1.44), major bleeding (aHR, 1.40), and recurrent VTE (aHR, 1.40) than patients with mild or no CKD.
Dr. Robert Greenwell, Chief of Nephrology at Mercy Medical Center in Baltimore, commented in an email to Reuters Health that treatment of VTE in the moderate-to-severe CKD patients, "should maybe be changed so that it is more like patients without CKD."
Like Dr. Goto, he noted that those with moderate-to-severe disease were much less likely to be treated with DOACs, "which is expected, as these agents are considered to possibly be more risky than standard warfarin" in these patients.
However, he added, DOACs "generally have had better outcomes with respect to VTE complications, including bleeding risk, and many clinicians feel that in the near term, they will be recommended as a first-line medication to use with VTE in patients with CKD, as well."
"My own feeling is that very soon, the way we manage VTE's in moderate/severe CKD - specifically with respect to DOACs - will be similar to less advanced kidney disease," he said. "This may help to at least lower some of the higher risk we now see with worsened renal disease."
The study was supported by an unrestricted research grant from Bayer Pharma AG. Several of the coauthors have received fees from Bayer.
By Marilynn Larkin
SOURCE: https://bit.ly/3knnYmd JAMA Network Open, online October 28, 2020.
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