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Abstract: TH-PO856

Fracture Risk in Association With Use of Anticoagulants for Atrial Fibrillation in Patients With CKD

Session Information

Category: CKD (Non-Dialysis)

  • 2201 CKD (Non-Dialysis): Epidemiology‚ Risk Factors‚ and Prevention

Authors

  • Khan, Nazleen, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, United States
  • Kim, Seoyoung C., Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, United States
  • Lee, Su Been, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, United States
  • Bykov, Katsiaryna, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, United States
  • Paik, Julie M., Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, United States
Background

Direct oral anticoagulant (DOAC) use has been associated with better safety outcomes relative to warfarin in patients with atrial fibrillation. However, little is known about the safety and effectiveness of anticoagulant therapy in patients with chronic kidney disease (CKD), who are predisposed to fractures and other adverse outcomes.

Methods

We conducted a new user, active comparator cohort study in a large US commercial insurance database (2013-2020). Individuals were required to have at least 365 days of continuous enrollment prior to anticoagulant initiation and at least one International Classification of Diseases (ICD) diagnosis code for CKD, stages 3-5, and atrial fibrillation during the baseline period. The primary outcome was non-vertebral fracture defined using a previously validated algorithm of ICD diagnosis and procedure codes. Primary analyses quantified fracture risk in patients initiating DOACs (apixaban or rivaroxaban) or warfarin using a 1:1 propensity score-matched design with adjustment for 82 covariates. Cox proportional hazards regression and modified generalized linear models were used to obtain adjusted hazard ratios (HRs) and rate differences and 95% confidence intervals (CIs) of fracture in the 365 days following anticoagulant initiation. Secondary analyses evaluated comparative risks of all-cause mortality and hip fracture.

Results

The matched population included 14,394 initiators of DOACs and warfarin, respectively. The mean age was 77 years (standard deviation 8), and 45% were female. The rate of fracture events per 1,000 person-years was 32.53 for DOAC users and 29.89 for warfarin users. The adjusted HR of fracture comparing DOACs to warfarin was 1.09 (95% CI 0.92 to 1.29), and the rate difference was 2.64 events per 1,000 person-years (95% CI -2.56 to 7.83). In secondary analyses, the adjusted HR comparing DOACs to warfarin was 0.87 (95% CI 0.81 to 0.93) for all-cause mortality and 1.23 (95% CI 0.91 to 1.65) for hip fracture.

Conclusion

In our study of CKD patients with atrial fibrillation, we did not observe a difference in the rates of fracture between DOACs and warfarin initiators; however, the use of DOACs was associated with a lower risk of all-cause mortality.