title: Novel oral anticoagulants in patients with renal insufficiency: a meta-analysis of randomized trials.
abstract: BACKGROUND
  Recent reports suggest altered antithrombotic efficacy and higher risk of bleeding with new oral anticoagulants (NOACs) in patients with renal insufficiency. A meta-analysis was performed to evaluate the efficacy and safety with recommended doses of NOAC compared with conventional treatment in patients with renal insufficiency.
  
  
  METHODS
  PubMed, Cochrane Library, EMBASE, EBSCO, Web of Science, and CINAHL databases were searched from January 1, 2001 through March 23, 2014. Randomized controlled trials that compared NOACs (rivaroxaban, apixaban, and dabigatran) with comparators (vitamin K antagonist/warfarin, low molecular weight heparin, aspirin, placebo) were selected. We defined moderate renal insufficiency as creatinine clearance (estimated glomerular filtration rate [eGFR]) of 30-49 mL/min, and mild renal insufficiency as eGFR 50-79 mL/min.
  
  
  RESULTS
  There were 40,693 patients with renal insufficiency in 10 trials. Compared with other anticoagulants in patients with mild renal insufficiency there was significantly less major or clinically relevant nonmajor bleeding (odds ratio [OR], 0.81; 95% confidence interval [CI], 0.72-0.90) and stroke or systemic embolism (OR, 0.70; 95% CI, 0.54-0.92) with NOACs. Using random effects meta-analysis, there was significantly less stroke or systemic embolism (OR, 0.72; 95% CI, 0.57-0.92) and a trend toward less major or clinically relevant nonmajor bleeding (OR, 0.82; 95% CI, 0.59-1.14) with the NOACs among patients with moderate renal insufficiency, and this became statistically significant when evaluated using a fixed effects model. NOACs showed efficiency comparable with conventional anticoagulants for prevention of venous thromboembolism or related mortality.
  
  
  CONCLUSIONS
  In patients with renal insufficiency, recommended doses of novel anticoagulants are noninferior and relatively safe compared with conventional anticoagulants.
authors: Department of Cardiology, Texas Tech University Health Sciences Center, El Paso, Texas, USA. Electronic address: parthasardarmd@gmail.com.
authors: Partha
authors: P
authors: Sardar
authors: Department of Cardiovascular Diseases, St Luke's-Roosevelt Hospital of the Mount Sinai Health System, New York, New York, USA.
authors: Saurav
authors: S
authors: Chatterjee
authors: Department of Cardiovascular Diseases, St Luke's-Roosevelt Hospital of the Mount Sinai Health System, New York, New York, USA.
authors: Eyal
authors: E
authors: Herzog
authors: Department of Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
authors: Ramez
authors: R
authors: Nairooz
authors: Department of Cardiology, Texas Tech University Health Sciences Center, El Paso, Texas, USA.
authors: Debabrata
authors: D
authors: Mukherjee
authors: Department of Cardiovascular Diseases, The Cardiovascular Institute, Mount Sinai Medical Center, New York, New York, USA.
authors: Jonathan L
authors: JL
authors: Halperin
mesh_terms: D000284:Administration, Oral; D000925:Anticoagulants / Q000627:therapeutic use*; D001562:Benzimidazoles / Q000627:therapeutic use; D000069604:Dabigatran; D006470:Hemorrhage / Q000139:chemically induced / Q000517:prevention & control; D006801:Humans; D009025:Morpholines / Q000627:therapeutic use; D011720:Pyrazoles / Q000627:therapeutic use; D011728:Pyridones / Q000627:therapeutic use; D016032:Randomized Controlled Trials as Topic; D051437:Renal Insufficiency / Q000097:blood / Q000150:complications*; D000069552:Rivaroxaban; D020521:Stroke / Q000517:prevention & control*; D013876:Thiophenes / Q000627:therapeutic use; D013923:Thromboembolism / Q000517:prevention & control*; D015091:beta-Alanine / Q000031:analogs & derivatives / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D001562:Benzimidazoles; D009025:Morpholines; D011720:Pyrazoles; D011728:Pyridones; D013876:Thiophenes; D015091:beta-Alanine; C522181:apixaban; D000069552:Rivaroxaban; D000069604:Dabigatran