Objective To assess the association between anticoagulation, ischaemic stroke, gastrointestinal and cerebral haemorrhage, and all cause mortality in older people with atrial fibrillation and chronic kidney disease.
Design Propensity matched, population based, retrospective cohort analysis from January 2006 through December 2016.
Setting The Royal College of General Practitioners Research and Surveillance Centre database population of almost 2.73 million patients from 110 general practices across England and Wales.
Participants Patients aged 65 years and over with a new diagnosis of atrial fibrillation and estimated glomerular filtration rate (eGFR) of <50 mL/min/1.73m², calculated using the chronic kidney disease epidemiology collaboration creatinine equation. Patients with a previous diagnosis of atrial fibrillation or receiving anticoagulation in the preceding 120 days were excluded, as were patients requiring dialysis and recipients of renal transplants.
Intervention Receipt of an anticoagulant prescription within 60 days of atrial fibrillation diagnosis.
Main outcome measures Ischaemic stroke, cerebral or gastrointestinal haemorrhage, and all cause mortality.
Results 6977 patients with chronic kidney disease and newly diagnosed atrial fibrillation were identified, of whom 2434 were on anticoagulants within 60 days of diagnosis and 4543 were not. 2434 pairs were matched using propensity scores by exposure to anticoagulant or none and followed for a median of 506 days. The crude rates for ischaemic stroke and haemorrhage were 4.6 and 1.2 after taking anticoagulants and 1.5 and 0.4 in patients who were not taking anticoagulant per 100 person years, respectively. The hazard ratios for ischaemic stroke, haemorrhage, and all cause mortality for those on anticoagulants were 2.60 (95% confidence interval 2.00 to 3.38), 2.42 (1.44 to 4.05), and 0.82 (0.74 to 0.91) compared with those who received no anticoagulation.
Conclusion Giving anticoagulants to older people with concomitant atrial fibrillation and chronic kidney disease was associated with an increased rate of ischaemic stroke and haemorrhage but a paradoxical lowered rate of all cause mortality. Careful consideration should be given before starting anticoagulants in older people with chronic kidney disease who develop atrial fibrillation. There remains an urgent need for adequately powered randomised trials in this population to explore these findings and to provide clarity on correct clinical management.

中文翻译：

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老年慢性肾脏病患者的缺血性中风，出血和死亡率是通过抗凝治疗房颤新开始的：一项来自英国基层医疗机构的人群研究

目的探讨抗凝，缺血性中风，胃肠道和脑出血与老年人房颤和慢性肾脏病的所有病因死亡率之间的关系。从2006年1月到2016年12月，
设计倾向匹配的，基于人群的回顾性队列分析。
设置皇家全科医师研究与监视中心的数据库，涵盖英格兰和威尔士110个常规诊所的近273万患者。
研究对象65岁及以上的患者，新诊断为房颤，估计肾小球滤过率（eGFR）<50 mL / min / 1.73m ²，使用慢性肾脏病流行病学协作肌酐方程计算。排除先前有心房颤动诊断或在前120天内接受抗凝治疗的患者，以及需要透析的患者和接受肾移植的患者。心房颤动诊断后60天内抗凝处方的
干预收据。
主要预后指标缺血性中风，脑或胃肠道出血，均会导致死亡。
结果确定了6977例患有慢性肾脏疾病和新诊断为房颤的患者，其中2434例在诊断后60天内接受了抗凝治疗，而4543例则没有。使用倾向评分通过与抗凝剂接触或不接触对2434对进行配对，中位数为506天。服用抗凝剂后的缺血性卒中和出血的毛发生率分别为4.6和1.2，而每100人年不服用抗凝剂的患者的毛发生率分别为1.5和0.4。与未接受抗凝治疗的患者相比，接受抗凝治疗的患者的缺血性中风，出血和所有原因致死的风险比分别为2.60（95％置信区间2.00-3.38），2.42（1.44-4.05）和0.82（0.74-0.91）。 。
结论给伴有心房纤颤和慢性肾脏疾病的老年人服用抗凝剂，会增加缺血性中风和出血的发生率，但所有病因死亡率却反而降低。在患有房颤的患有慢性肾脏疾病的老年人中开始使用抗凝剂之前，应仔细考虑。迫切需要在这一人群中进行充分有力的随机试验，以探索这些发现并明确正确的临床治疗方法。