Predictions of adverse outcomes using different renal function estimation formulas in patients with atrial fibrillation receiving direct oral anticoagulants

Abstract Background The Cockcroft-Gault (CG) formula remains the gold standard for renal function assessment in patients with atrial fibrillation (AF) receiving direct oral anticoagulants (DOACs), though various other estimation formulas exist. We compared the concordance and predictive performance of different renal function formulas regarding clinical outcomes in patients with AF receiving DOAC therapy. Methods A total of 21,318 patients with non-valvular AF receiving DOACs was studied. Renal function was estimated using eight formulas, including CG, MDRD, and CKD-EPI. Concordance was assessed utilizing weighted Cohen’s Kappa. The accuracies of different renal function equations in predicting composite clinical outcomes (thromboembolism, all-cause mortality, and major bleeding) were assessed using receiver operating characteristic (ROC) curves. Results Most patients were classified as having chronic kidney disease (CKD) stage 2 across the eight renal function formulas, with proportions ranging from 29.2% using the CG formula to 48.2% using the CKD-EPI formula. The concordance between the CG and MDRD (K=0.498; 95%CI, 0.481-0.515) or CKD-EPI (K=0.485; 95%CI, 0.468-0.502) formula is only moderate (Figure 1). Both the MDRD (AUC: 0.641; 95% CI: 0.633–0.649) and CKD-EPI (AUC: 0.664; 95% CI: 0.656–0.672) formulas, along with other renal function equations, demonstrated inferior discriminatory performance for predicting major adverse events compared with the Cockcroft–Gault formula (AUC: 0.707; 95% CI: 0.690–0.704), regardless of whether eGFR was analyzed as a continuous variable (Figure 2A) or categorized into six CKD stages (Figure 2B). Conclusions The CG formula plays a crucial role in the management of patients with AF in the DOAC era, as it is essential for both dose guidance and the prediction of adverse clinical events.figure--1--correlation.jpgfigure--2--renal--equation--figure.jpg