Page 59 - 林口長庚醫研部電子報-2018年9月刊

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7 主題：心房顫動患者使用抗凝血藥發生急性腎衰竭 Warfarin also facilitates renal vascular calcification and the consequent

之風險探討 decline in renal function via inhibition of the activation of matrix

撰稿者 / 校稿者：林口長庚醫院心臟內科詹益欣醫師 G1a protein and growth arrest specific gene 6 (GAS-6) (Figure 1).

論文資訊 : The risk of acute kidney injury in Asians treated with apixaban,rivaroxaban, Recently, direct oral anti-coagulants (DOACs), including apixaban,
dabigatran, or warfarin for non-valvular atrial fibrillation: A nationwide cohort study in dabigatran, rivaroxaban, and edoxaban, are increasingly used for the
Taiwan prevention of ischemic stroke and systemic embolism in non-valvular AF
INTERNATIONAL JOURNAL OF CARDIOLOGY, AUG. 2018
IF= 6.189 (12.7%) patients as a safer alternative to warfarin with a lower risk of intracranial

第一作者：林口長庚醫院心臟內科詹益欣醫師 hemorrhage and other causes of major bleeding. DOACs are all excreted

指導作者：林口長庚醫院風濕免疫科郭昶甫醫師、林口長庚醫院心臟內科郭啟泰醫師 through the kidney in different portions, with around 27% renal excretion
of apixaban and ~80% renal excretion of dabigatran. Recent meta-

研究目的背景： analysis showed that the risk of renal failure associated with NOACs

Whether the direct oral anticoagulant (DOAC) is associated with a lower (dabigatran, apixaban, and/or rivaroxaban) was similar to the traditional

risk of acute kidney injury (AKI) among patients with non-valvular atrial anticoagulants including warfarin and low molecular weight heparin

fibrillation (NVAF) taking oral anticoagulant remains unknown in real (LMWH).10 Of note, rivaroxaban was associated with an adverse effect

world. of serum creatinine elevation in some studies. Whether the DOACs with
its anticoagulant mechanism independent from the Vitamin K related
研究發現與應用： cascade, is associated with a lower risk of acute kidney injury (AKI) in

Oral anticoagulants (OACs), like Vitamin K antagonists (VKAs) patients with non-valvular atrial fibrillation (NVAF) remains unknown.

(e.g., warfarin), have been shown to effectively decrease the risk By using the Taiwan nationwide retrospective cohort study, 7,702

of thromboembolic events and all-cause mortality in patients with and 7,885 NVAF patients without a history of chronic kidney disease
atrial fibrillation (AF). Meanwhile, OACs can also increase the risk of (CKD) and 2,256 and 2,089 NVAF patients with a history of CKD

hemorrhage due to coagulopathy. Although warfarin has been commonly taking dabigatran and warfarin, respectively, from February 1, 2013 to

used for over 60 years, its harmful effects on renal function, so-called December 31, 2013 were analysed. Propensity-score weighted method

warfarin-related nephropathy (WRN), have only recently been recognized. was used to balance covariates across study groups. Dabigatran was

It is estimated that as high as 20.5% of all patients taking warfarin have associated with a lower risk of AKI comparing with warfarin for either

experienced at least one episode of WRN during their treatment course, CKD-free [Hazard ratio (HR):0.62; 95% confidence interval (CI): 0.49-

with most cases occurring within 1 year after the initiation of treatment. 0.77;P <.001] or CKD cohort [HR:0.56;95% CI: 0.46-0.69;P <.001].As

The mechanisms underlying WRN are complicated and multifactorial the increment in CHA2D-VASc score from 0/1 to 6+ points, the annual

but supra-therapeutic doses of warfarin with an International Normalized incidence of AKI for the dabigatran group was relatively stable (1.87 to
Ratio (INR) of > 3.0 may result in glomerular hemorrhage and consequent 2.91%/year for CKD-free cohort; 7.31% to 13.15%/year for CKD cohort),

tubular injury caused by obstructive tubular RBC casts and heme-induced but increased obviously for patients taking warfarin for either CKD-free

free radical injury. (2.16 to 6.12%/year) or CKD cohorts (6.82 to 26.03%/year).

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