title: Warfarin utilisation and anticoagulation control in patients with atrial fibrillation and chronic kidney disease.
abstract: To evaluate warfarin prescription, quality of international normalised ratio (INR) monitoring and of INR control in patients with atrial fibrillation (AF) and chronic kidney disease (CKD).
  
  
  
  We performed a retrospective cohort study of patients with newly diagnosed AF in the Veterans Administration (VA) healthcare system. We evaluated anticoagulation prescription, INR monitoring intensity and time in and outside INR therapeutic range (TTR) stratified by CKD.
  
  
  
  Of 123 188 patients with newly diagnosed AF, use of warfarin decreased with increasing severity of CKD (57.2%-46.4%), although it was higher among patients on dialysis (62.3%). Although INR monitoring intensity was similar across CKD strata, the proportion with TTR≥60% decreased with CKD severity, with only 21% of patients on dialysis achieving TTR≥60%. After multivariate adjustment, the magnitude of TTR reduction increased with CKD severity. Patients on dialysis had the highest time markedly out of range with INR <1.5 or >3.5 (30%); 12% of INR time was >3.5, and low TTR persisted for up to 3 years.
  
  
  
  There is a wide variation in anticoagulation prescription based on CKD severity. Patients with moderate-to-severe CKD, including dialysis, have substantially reduced TTR, despite comparable INR monitoring intensity. These findings have implications for more intensive warfarin management strategies in CKD or alternative therapies such as direct oral anticoagulants.
authors.affiliation: Maimonides Medical Center, Brooklyn, New York, USA.
authors.forename: Felix
authors.identifier: 0000-0001-8751-6752
authors.initials: F
authors.lastname: Yang
authors.affiliation: Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA.
authors.forename: Jessica A
authors.initials: JA
authors.lastname: Hellyer
authors.affiliation: Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA.
authors.forename: Claire
authors.initials: C
authors.lastname: Than
authors.affiliation: Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA.|Stanford University School of Medicine, Stanford, California, USA.
authors.forename: Aditya J
authors.initials: AJ
authors.lastname: Ullal
authors.affiliation: Stanford University School of Medicine, Stanford, California, USA.
authors.forename: Daniel W
authors.initials: DW
authors.lastname: Kaiser
authors.affiliation: Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA.|Stanford University School of Medicine, Stanford, California, USA.
authors.forename: Paul A
authors.initials: PA
authors.lastname: Heidenreich
authors.affiliation: Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA.
authors.forename: Donald D
authors.initials: DD
authors.lastname: Hoang
authors.affiliation: Stanford University School of Medicine, Stanford, California, USA.|Baylor College of Medicine, Houston, Texas, USA.
authors.forename: Wolfgang C
authors.initials: WC
authors.lastname: Winkelmayer
authors.affiliation: Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA.
authors.forename: Susan
authors.initials: S
authors.lastname: Schmitt
authors.affiliation: Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA.|Stanford University School of Medicine, Stanford, California, USA.
authors.forename: Susan M
authors.initials: SM
authors.lastname: Frayne
authors.affiliation: Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA.|Stanford University School of Medicine, Stanford, California, USA.
authors.forename: Ciaran S
authors.initials: CS
authors.lastname: Phibbs
authors.affiliation: Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA.|Stanford University School of Medicine, Stanford, California, USA.
authors.forename: Mintu P
authors.initials: MP
authors.lastname: Turakhia
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage; D001281:Atrial Fibrillation / Q000150:complications / Q000188:drug therapy*; D004305:Dose-Response Relationship, Drug; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D051436:Renal Insufficiency, Chronic / Q000150:complications* / Q000188:drug therapy; D012189:Retrospective Studies; D020521:Stroke / Q000209:etiology / Q000517:prevention & control*; D013997:Time Factors; D016896:Treatment Outcome; D014859:Warfarin / Q000008:administration & dosage*
chemical_list: D000925:Anticoagulants; D014859:Warfarin