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Kao T, Chen Z, Lin Y. Anticoagulation for Patients With Concomitant Atrial Fibrillation and End-Stage Renal Disease: A Systematic Review and Network Meta-Analysis. J Am Heart Assoc 2024; 13:e034176. [PMID: 38606775 PMCID: PMC11262503 DOI: 10.1161/jaha.123.034176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 03/19/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Concomitant atrial fibrillation and end-stage renal disease is common and associated with an unfavorable prognosis. Although oral anticoagulants have been well established to prevent thromboembolism, the applicability in patients under long-term dialysis remains debatable. The study aimed to determine the efficacy and safety of anticoagulation in the dialysis-dependent population. METHODS AND RESULTS An updated network meta-analysis based on MEDLINE, EMBASE, and the Cochrane Library was performed. Studies published up to December 2022 were included. Direct oral anticoagulants (DOACs, dabigatran, rivaroxaban, apixaban 2.5/5 mg twice daily), vitamin K antagonists (VKAs), and no anticoagulation were compared on safety and efficacy outcomes. The outcomes of interest were major bleeding, thromboembolism, and all-cause death. A total of 42 studies, including 3 randomized controlled trials, with 185 864 subjects were pooled. VKAs were associated with a significantly higher risk of major bleeding than either no anticoagulation (hazard ratio [HR], 1.47; 95% CI, 1.34-1.61) or DOACs (DOACs versus VKAs; HR, 0.74 [95% CI, 0.64-0.84]). For the prevention of thromboembolism, the efficacies of VKAs, DOACs, and no anticoagulation were equivalent. Nevertheless, dabigatran and rivaroxaban were associated with fewer embolic events. There were no differences in all-cause death with the administration of VKAs, DOACs, or no anticoagulation. CONCLUSIONS For dialysis-dependent populations, dabigatran and rivaroxaban were associated with better efficacy, while dabigatran and apixaban demonstrated better safety. No anticoagulation was a noninferior alterative, and VKAs were associated with the worst outcomes.
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Affiliation(s)
- Ting‐Wei Kao
- Department of Internal MedicineNational Taiwan University Hospital and National Taiwan University College of MedicineTaipeiTaiwan
| | - Zheng‐Wei Chen
- Department of Internal MedicineNational Taiwan University Hospital and National Taiwan University College of MedicineTaipeiTaiwan
- Department of Internal MedicineNational Taiwan University Hospital Yun‐Lin BranchYun‐LinTaiwan
- Graduate Institute of Clinical Medicine, National Taiwan University HospitalTaipeiTaiwan
| | - Yen‐Hung Lin
- Department of Internal MedicineNational Taiwan University Hospital and National Taiwan University College of MedicineTaipeiTaiwan
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Law MM, Tan SJ, Wong MC, Toussaint ND. Atrial Fibrillation in Kidney Failure: Challenges in Risk Assessment and Anticoagulation Management. Kidney Med 2023; 5:100690. [PMID: 37547561 PMCID: PMC10403723 DOI: 10.1016/j.xkme.2023.100690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Abstract
Management of atrial fibrillation (AF) is a clinical conundrum in people with kidney failure. Stroke risk is disproportionately high, but clinicians have a limited armamentarium to improve outcomes in this population in whom there is a concurrently high bleeding risk. Direct oral anticoagulants may have a superior benefit-risk profile compared with vitamin K antagonists in people on hemodialysis. Although research has predominantly focused on identifying a safe and effective oral anticoagulation option to reduce stroke risk in people with kidney failure (and predominantly those on hemodialysis), it remains uncertain how clinicians discriminate between people who would derive net clinical benefit as opposed to net harm. The recommended CHA2DS2-VASc score cutoffs provide poor discriminatory value, and there is an urgent need to identify robust markers of thromboembolic risk in kidney failure. There is increasing data to challenge the prior dogma of risk equivalence across AF type, and the American Heart Association highlights moving beyond AF as a binary entity to consider the prognostic significance of AF burden. Implantable cardiac monitor studies reveal high rates and varied burden of subclinical and paroxysmal AF in people on hemodialysis. The association between AF burden and the proarrhythmic environment of hemodialysis with cyclical volume loading, offloading, and electrolyte changes is not well studied. We review the significance of AF burden as a contributor to thromboembolic risk, its potential as the missing link in risk assessment, and updated evidence for anticoagulation in people with kidney failure.
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Affiliation(s)
- Mandy M. Law
- Department of Nephrology, the Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Sven-Jean Tan
- Department of Nephrology, the Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Michael C.G. Wong
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Department of Cardiology, the Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Nigel D. Toussaint
- Department of Nephrology, the Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
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Cho MS, Choi HO, Hwang KW, Kim J, Nam GB, Choi KJ. Clinical benefits and risks of anticoagulation therapy according to the degree of chronic kidney disease in patients with atrial fibrillation. BMC Cardiovasc Disord 2023; 23:209. [PMID: 37098477 PMCID: PMC10131393 DOI: 10.1186/s12872-023-03236-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 04/11/2023] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND The clinical benefits and risks of anticoagulation therapy in patients with chronic kidney disease (CKD) are still inconclusive. We describe the outcomes of patients with atrial fibrillation (AF) after anticoagulation therapy according to differences in creatinine clearance (CrCl). We also aimed to determine the patients who could benefit from anticoagulation therapy. METHODS This is a retrospective observational review of patients with AF who were managed at Asan Medical Center (Seoul, Korea) between January 1, 2006, and December 31, 2018. Patients were categorized into groups according to their baseline CrCl by Cockcroft-Gault equation and their outcomes were evaluated (CKD 1, ≥ 90 mL/min; CKD2, 60-89 mL/min; CKD3, 30-59 mL/min; CKD4, 15-29 mL/min; CKD 5, < 15 mL/min). The primary outcome was NACE (net adverse clinical events), defined as a composite of all-cause mortality, thromboembolic events, and major bleeding. RESULTS We identified 12,714 consecutive patients with AF (mean 64.6 ± 11.9 years, 65.3% male, mean CHA2DS2-VASc score 2.4 ± 1.6 points) between 2006 and 2017. In patients receiving anticoagulation therapy (n = 4447, 35.0%), warfarin (N = 3768, 84.7%) was used more frequently than NOACs (N = 673, 15.3%). There was a higher 3-year rate of NACE with renal function deterioration (14.8%, 18.6%, 30.3%, 44.0%, and 48.8% for CKD stages 1-5, respectively).The clinical benefit of anticoagulation therapy was most prominent in patients with CKD 1 (hazard ratio [HR] 0.49, 95% confidence interval [CI] 0.37-0.67), 2 (HR 0.64 CI 0.54-0.76), and 3 (HR 0.64 CI 0.54-0.76), but not in CKD 4 (HR 0.86, CI 0.57-1.28) and 5 (HR 0.81, CI 0.47-1.40). Among patients with CKD, the benefit of anticoagulation therapy was only evident in those with a high risk of embolism (CHA2DS2-VASc score ≥ 4, HR 0.25, CI 0.08-0.80). CONCLUSION Advanced CKD is associated with a higher risk of NACE. The clinical benefit of anticoagulation therapy was reduced with the increasing CKD stage.
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Affiliation(s)
- Min Soo Cho
- Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyung Oh Choi
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, 170, Jomaru-ro, Bucheon-si, Gyeonggi-do, 14584, Republic of Korea.
| | - Ki Won Hwang
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan, Republic of Korea
| | - Jun Kim
- Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Gi-Byoung Nam
- Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kee-Joon Choi
- Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Malan IA. Atrial Fibrillation and Hemodialysis – Should we Anticoagulate These Patients? Ischemic Versus Hemorrhagic Risk. INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2022. [DOI: 10.36660/ijcs.20220171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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A systematic review of the efficacy and safety of anticoagulants in advanced chronic kidney disease. J Nephrol 2022; 35:2015-2033. [PMID: 36006608 PMCID: PMC9584987 DOI: 10.1007/s40620-022-01413-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/19/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) have an increased risk of venous thromboembolism (VTE) and atrial fibrillation (AF). Anticoagulants have not been studied in randomised controlled trials with CrCl < 30 ml/min. The objective of this review was to identify the impact of different anticoagulant strategies in patients with advanced CKD including dialysis. METHODS We conducted a systematic review of randomized controlled trials and cohort studies, searching electronic databases from 1946 to 2022. Studies that evaluated both thrombotic and bleeding outcomes with anticoagulant use in CrCl < 50 ml/min were included. RESULTS Our initial search yielded 14,503 papers with 53 suitable for inclusion. RCTs comparing direct oral anticoagulants (DOACs) versus warfarin for patients with VTE and CrCl 30-50 ml/min found no difference in recurrent VTE events (RR 0.68(95% CI 0.42-1.11)) with reduced bleeding (RR 0.65 (95% CI 0.45-0.94)). Observational data in haemodialysis suggest lower risk of recurrent VTE and major bleeding with apixaban versus warfarin. Very few studies examining outcomes were available for therapeutic and prophylactic dose low molecular weight heparin for CrCl < 30 ml/min. Findings for patients with AF on dialysis were that warfarin or DOACs had a similar or higher risk of stroke compared to no anticoagulation. For patients with AF and CrCl < 30 ml/min not on dialysis, anticoagulation should be considered on an individual basis, with limited studies suggesting DOACs may have a preferable safety profile. CONCLUSION Further studies are still required, some ongoing, in patients with advanced CKD (CrCl < 30 ml/min) to identify the safest and most effective treatment options for VTE and AF.
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Sousa M, Cruz G, Vilela S, Cardoso C, Bravo P, Santos JP, Santos C, Silva J. Hemorrhagic Versus Ischemic Risk in Patients with Atrial Fibrillation on Hemodialysis. INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2022. [DOI: 10.36660/ijcs.20210252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Akbar MR, Febrianora M, Iqbal M. Warfarin Usage in Patients with Atrial Fibrillation Undergoing Hemodialysis in Indonesian Population. Curr Probl Cardiol 2022; 48:101104. [PMID: 35041867 DOI: 10.1016/j.cpcardiol.2022.101104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/03/2022] [Indexed: 11/16/2022]
Abstract
The data about the efficacy and safety of warfarin usage in atrial fibrillation (AF) in hemodialysis patients is still limited, especially in the Asia population. The population of this study was end-stage renal disease patients with AF who underwent hemodialysis. The design of the study was a retrospective observational cohort that collected the patient data from 2016 to 2019. The Cox regression model was applied to assess the effect of warfarin on the outcomes. We conducted a survival analysis by comparing Kaplan-Meier curves using the log-rank test. We also measured the time in therapeutic range as a quality indicator of warfarin usage. Among 444 hemodialysis patients, 126 patients with AF matched the inclusion criteria, 88 patients completely followed up. Half patients used warfarin. The mean age was 52.2 ± 12.97 years, the mean follow-up duration was 11 ± 10 months. We observed all-cause death in 86.4% of patients, ischemic stroke in 10.2%, and hemorrhagic stroke in 2.3% of patients. There were no significant differences in all-cause death, ischemic stroke, and hemorrhagic stroke. Warfarin use was not associated with a lower rate for death (HR 0.782; 95% CI, 0.494-1.237, P = 0.293) or ischemic stroke (HR 0.435; 95% CI, 0.103-1.846, P = 0.259) or hemorrhagic stroke (HR 0.564; 95% CI, 0.034-9.386, P = 0.689). None of the patients reach the time in the therapeutic range >65%. Our findings suggest that warfarin has no association with mortality, ischemic stroke, and hemorrhagic stroke events rate in atrial fibrillation patients who underwent hemodialysis in the Indonesian population.
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Affiliation(s)
- Mohammad Rizki Akbar
- Department of Cardiology and Vascular Medicine, Hasan Sadikin General Hospital - Universitas Padjadjaran, Bandung, Indonesia.
| | - Mega Febrianora
- Department of Cardiology and Vascular Medicine, Hasan Sadikin General Hospital - Universitas Padjadjaran, Bandung, Indonesia
| | - Mohammad Iqbal
- Department of Cardiology and Vascular Medicine, Hasan Sadikin General Hospital - Universitas Padjadjaran, Bandung, Indonesia
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Goudis C, Daios S, Korantzopoulos P, Liu T. Does CHA2DS2-VASc score predict mortality in chronic kidney disease? Intern Emerg Med 2021; 16:1737-1742. [PMID: 34232486 PMCID: PMC8261034 DOI: 10.1007/s11739-021-02799-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/17/2021] [Indexed: 12/14/2022]
Abstract
Chronic kidney disease (CKD) is a leading cause of morbidity and mortality worldwide. Assessment of cardiovascular (CV) and all-cause mortality in CKD patients is of particular importance. CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75 years, diabetes, prior stroke, vascular disease, age 65-74 years, and sex) score was originally formulated to predict the annual thromboembolic risk in patients with nonvalvular atrial fibrillation (AF). The calculation of R2CHADS2 and R2CHA2DS2VASc scores awarded an additional 2 points for CrCl < 60 mL/min and GFR < 60 mL/min/1.73 m2. Recent studies have investigated whether CHA2DS2-VASc and R2CHADS ± VASC scores could be used to predict CV or all-cause mortality in patients with CKD. CHA2DS2-VASc score was proven to be a significant predictor of CV and all-cause mortality in CKD patients, and a higher CHA2DS2-VASc score was associated with increased mortality. These findings are quite promising, and they may help physicians to identify high-risk groups in this population.
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Affiliation(s)
- Christos Goudis
- Department of Cardiology, Serres General Hospital, 45110, Serres, Greece.
| | - Stylianos Daios
- Department of Cardiology, Serres General Hospital, 45110, Serres, Greece
| | | | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, 300211, People's Republic of China
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Bel-Ange A, Itskovich SZ, Avivi L, Stav K, Efrati S, Beberashvili I. Prior ischemic strokes are non-inferior for predicting future ischemic strokes than CHA 2DS 2-VASc score in hemodialysis patients with non-valvular atrial fibrillation. BMC Nephrol 2021; 22:179. [PMID: 33992086 PMCID: PMC8126112 DOI: 10.1186/s12882-021-02384-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/20/2021] [Indexed: 11/23/2022] Open
Abstract
Background We tested whether CHA2DS2-VASc and/or HAS-BLED scores better predict ischemic stroke and major bleeding, respectively, than their individual components in maintenance hemodialysis (MHD) patients with atrial fibrillation (AF). Methods A retrospective cohort study of a clinical database containing the medical records of 268 MHD patients with non-valvular AF (167 women, mean age 73.4 ± 10.2 years). During the median follow-up of 21.0 (interquartile range, 5.0–44.0) months, 46 (17.2%) ischemic strokes and 24 (9.0%) major bleeding events were reported. Results Although CHA2DS2-VASc predicted ischemic stroke risk in the study population (adjusted HR 1.74 with 95% CI 1.23–2.46 for each unit of increase in CHA2DS2-VASc score, and HR of 5.57 with 95% CI 1.88–16.49 for CHA2DS2-VASc score ≥ 6), prior ischemic strokes/transient ischemic attacks (TIAs) were non-inferior in both univariate and multivariate analyses (adjusted HR 8.65 with 95% CI 2.82–26.49). The ROC AUC was larger for the prior ischemic stroke/TIA than for CHA2DS2-VASc. Furthermore, the CHA2DS2-VASc score did not predict future ischemic stroke risks in study participants who did not previously experience ischemic strokes/TIAs (adjusted HR 1.41, 95% CI: 0.84–2.36). The HAS-BLED score and its components did not have predictive abilities in discriminating bleeding risk in the study population. Conclusions Previous ischemic strokes are non-inferior for predicting of future ischemic strokes than the complete CHA2DS2-VASc score in MHD patients. CHA2DS2VASc scores are less predictive in MHD patients without histories of CVA/TIA. HAS-BLED scores do not predict major bleeding in MHD patients. These findings should redesign approaches to ischemic stroke risk stratification in MHD patients if future large-scale epidemiological studies confirm them.
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Affiliation(s)
- Anat Bel-Ange
- Internal Department C, affiliated with the Sackler Faculty of Medicine, Yitzhak Shamir Medical Center, Tel Aviv University, Zerifin, Israel
| | - Shani Zilberman Itskovich
- Nephrology Division, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Yitzhak Shamir Medical Center, 70300, Zerifin, Israel
| | - Liana Avivi
- Internal Department D, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Yitzhak Shamir Medical Center, Zerifin, Israel
| | - Kobi Stav
- Urology Department, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Yitzhak Shamir Medical Center, Zerifin, Israel
| | - Shai Efrati
- Nephrology Division, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Yitzhak Shamir Medical Center, 70300, Zerifin, Israel
| | - Ilia Beberashvili
- Nephrology Division, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Yitzhak Shamir Medical Center, 70300, Zerifin, Israel.
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Su X, Yan B, Wang L, Lv J, Cheng H, Chen Y. Oral Anticoagulant Agents in Patients With Atrial Fibrillation and CKD: A Systematic Review and Pairwise Network Meta-analysis. Am J Kidney Dis 2021; 78:678-689.e1. [PMID: 33872690 DOI: 10.1053/j.ajkd.2021.02.328] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 02/02/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To evaluate the relative efficacy and safety of different oral anticoagulant agents (OACs) for patients with atrial fibrillation (AF) and chronic kidney disease (CKD). STUDY DESIGN Systematic review and pairwise and Bayesian network meta-analysis. SETTING & STUDY POPULATIONS Adult patients with AF and CKD stages 3-5D who received OACs. SELECTION CRITERIA FOR STUDIES Randomized controlled trials (RCTs) and observational studies that reported the efficacy and safety outcomes of subgroups with a glomerular filtration rate (GFR)<60mL/min. DATA EXTRACTION Two reviewers independently abstracted data, assessed study quality, and rated the strength of evidence (SOE). ANALYTICAL APPROACH Random-effects models using restricted maximum-likelihood methods were fit for the pairwise meta-analyses as well as a network meta-analysis within a Bayesian framework. RESULTS Pairwise meta-analysis including 8 RCTs and 46 observational studies showed that direct OACs (DOACs) were superior to warfarin in preventing thromboembolic events (hazard ratio [HR], 0.86 [95% CI, 0.78-0.95]), without heterogeneity (I2=10.5%), and in reducing the risk of bleeding events (HR, 0.81 [95% CI, 0.66-0.99]), with substantial heterogeneity (I2=69.8%), in patients with AF and a GFR of 15-60mL/min. Bayesian network meta-analysis including 8 RCTs showed that dose-adjusted apixaban and a 15-mg dose of edoxaban were superior to the other OAC regimens in reducing bleeding events. Dose-adjusted apixaban was more effective than edoxaban in preventing thromboembolic events for patients with AF and GFR in the range of 25-50 or 30-50mL/min. In dialysis recipients with AF, the use of OACs increased the risk of bleeding events by 28% (HR, 1.28 [95% CI, 1.03-1.60]) without significant beneficial effects versus not using anticoagulants. LIMITATIONS Low SOE and heterogeneity in most comparisons. CONCLUSIONS This study suggests that DOACs are superior to warfarin for the prevention of thromboembolic events and reduction in bleeding risk in patients with AF and mild to moderate kidney disease. However, the low SOE limits the conclusions that can be drawn about the preferred DOAC. Notably, the use of OACs may increase bleeding risk without significant benefits in dialysis recipients with AF. REGISTRATION Registered at PROSPERO with identification number CRD42018090896.
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Affiliation(s)
- Xiaole Su
- Division of Nephrology, Beijing Anzhen Hospital, Capital Medical University; Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, China
| | - Bingjuan Yan
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, China
| | - Lihua Wang
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, China
| | - Jicheng Lv
- Division of Nephrology, Peking University First Hospital, Peking University Institute of Nephrology, Beijing
| | - Hong Cheng
- Division of Nephrology, Beijing Anzhen Hospital, Capital Medical University
| | - Yipu Chen
- Division of Nephrology, Beijing Anzhen Hospital, Capital Medical University.
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Ding WY, Gupta D, Wong CF, Lip GYH. Pathophysiology of atrial fibrillation and chronic kidney disease. Cardiovasc Res 2020; 117:1046-1059. [PMID: 32871005 DOI: 10.1093/cvr/cvaa258] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 07/28/2020] [Accepted: 08/25/2020] [Indexed: 01/06/2023] Open
Abstract
Atrial fibrillation (AF) and chronic kidney disease (CKD) are closely related conditions with shared risk factors. The growing prevalence of both AF and CKD indicates that more patients will suffer from concurrent conditions. There are various complex interlinking mechanisms with important implications for the management of these patients. Furthermore, there is uncertainty regarding the use of oral anticoagulation (OAC) in AF and CKD that is reflected by a lack of consensus between international guidelines. Therefore, the importance of understanding the implications of co-existing AF and CKD should not be underestimated. In this review, we discuss the pathophysiology and association between AF and CKD, including the underlying mechanisms, risk of thrombo-embolic and bleeding complications, influence on stroke management, and evidence surrounding the use of OAC for stroke prevention.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Christopher F Wong
- Department of Renal Medicine, Liverpool University Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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de Jong Y, Ramspek CL, van der Endt VHW, Rookmaaker MB, Blankestijn PJ, Vernooij RWM, Verhaar MC, Bos WJW, Dekker FW, Ocak G, van Diepen M. A systematic review and external validation of stroke prediction models demonstrates poor performance in dialysis patients. J Clin Epidemiol 2020; 123:69-79. [PMID: 32240769 DOI: 10.1016/j.jclinepi.2020.03.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 02/20/2020] [Accepted: 03/19/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVES The objective of this study was to systematically review and externally assess the predictive performance of models for ischemic stroke in incident dialysis patients. STUDY DESIGN AND SETTING Two reviewers systematically searched and selected ischemic stroke models. Risk of bias was assessed with the PROBAST. Predictive performance was evaluated within The Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD), a large prospective multicenter cohort of incident dialysis patients. For discrimination, c-statistics were calculated; calibration was assessed by plotting predicted and observed probabilities for stroke, and calibration-in-the-large. RESULTS Seventy-seven prediction models for stroke were identified, of which 15 were validated. Risk of bias was high, with all of these models scoring high risk in one or more domains. In NECOSAD, of the 1,955 patients, 127 (6.5%) suffered an ischemic stroke during the follow-up of 2.5 years. Compared with the original studies, most models performed worse with all models showing poor calibration and discriminative abilities (c-statistics ranging from 0.49 to 0.66). The Framingham showed reasonable calibration; however, with a c-statistic of 0.57 (95% CI 0.50-0.63), the discrimination was poor. CONCLUSION This external validation demonstrates the weak predictive performance of ischemic stroke models in incident dialysis patients. Instead of using these models in this fragile population, either existing models should be updated, or novel models should be developed and validated.
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Affiliation(s)
- Ype de Jong
- Department of Clinical Epidemiology, Leiden University Medical Center (LUMC), Leiden, The Netherlands; Department of Internal Medicine, Leiden University Medical Center (LUMC), Leiden, The Netherlands.
| | - Chava L Ramspek
- Department of Clinical Epidemiology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Vera H W van der Endt
- Department of Clinical Epidemiology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Maarten B Rookmaaker
- Department of Nephrology and Hypertension, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Peter J Blankestijn
- Department of Nephrology and Hypertension, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Robin W M Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marianne C Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Willem Jan W Bos
- Department of Internal Medicine, Leiden University Medical Center (LUMC), Leiden, The Netherlands; Department of Internal Medicine, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Gurbey Ocak
- Department of Nephrology and Hypertension, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Merel van Diepen
- Department of Clinical Epidemiology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
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Randhawa MS, Vishwanath R, Rai MP, Wang L, Randhawa AK, Abela G, Dhar G. Association Between Use of Warfarin for Atrial Fibrillation and Outcomes Among Patients With End-Stage Renal Disease: A Systematic Review and Meta-analysis. JAMA Netw Open 2020; 3:e202175. [PMID: 32250434 PMCID: PMC7136833 DOI: 10.1001/jamanetworkopen.2020.2175] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE Several studies have examined the role of warfarin in preventing strokes in patients with atrial fibrillation and end-stage renal disease; however, the results remain inconclusive. OBJECTIVE To assess recently published studies to examine the outcomes of the use of warfarin among patients with atrial fibrillation and end-stage renal disease. DATA SOURCES A literature search was performed using the terms warfarin and atrial fibrillation and end-stage renal disease and warfarin and atrial fibrillation and dialysis in the MEDLINE, Embase, and Google Scholar databases from January 1, 2008, to February 28, 2019. STUDY SELECTION The studies included were those with patients with end-stage renal disease and atrial fibrillation who were receiving warfarin and with hazard ratios (HRs) of at least 1 primary outcome. The studies excluded were those with a lack of information on outcomes and unreliable 95% CIs of the results. DATA EXTRACTION AND SYNTHESIS The Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines were followed in selecting studies. Collected data were also scrutinized for reliable 95% CIs. Finally, studies were examined for perceived biases, their limitations, and the definitions of the outcomes. MAIN OUTCOMES AND MEASURES The HRs and 95% CIs were calculated for the incidence of ischemic stroke, hemorrhagic stroke, major bleeding, and mortality among patients receiving anticoagulants and those not receiving anticoagulants. RESULTS Study selection yielded 15 studies with a total of 47 480 patients with atrial fibrillation and end-stage renal disease. Of these patients, 10 445 (22.0%) were taking warfarin. With a mean (SD) follow-up period of 2.6 (1.4) years, warfarin use was associated with no significant change for the risk of ischemic stroke (HR, 0.96; 95% CI, 0.82-1.13), with a significantly higher risk of hemorrhagic stroke (HR, 1.49; 95% CI, 1.03-1.94), with no significant difference in the risk of major bleeding (HR, 1.20; 95% CI, 0.99-1.47), and with no change in overall mortality (HR, 0.95; 95% CI, 0.83-1.09). CONCLUSIONS AND RELEVANCE In the studies reviewed, warfarin use appears to have been associated with no change in the incidence of ischemic stroke in patients with atrial fibrillation and end-stage renal disease. However, from the studies reviewed, it does appear to be associated with a significantly higher risk of hemorrhagic stroke, with no significant difference in the risk of major bleeding, and with no change in mortality.
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Affiliation(s)
- Mandeep S. Randhawa
- Division of Cardiology, Michigan State University, Kalamazoo
- Sparrow Clinical Research Institute, Sparrow Healthcare, Lansing, Michigan
| | | | - Manoj P. Rai
- Department of Medicine, Michigan State University, East Lansing
| | - Ling Wang
- Division of Occupational and Environment Medicine, Michigan State University, East Lansing
| | | | - George Abela
- Division of Cardiology, Michigan State University, Kalamazoo
| | - Gaurav Dhar
- Division of Cardiology, Michigan State University, Kalamazoo
- Sparrow Clinical Research Institute, Sparrow Healthcare, Lansing, Michigan
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Baek SD, Jeung S, Kang JY, Jeon KH. Dialysis-specific factors and incident atrial fibrillation in hemodialysis patients. Ren Fail 2020; 42:785-791. [PMID: 32779958 PMCID: PMC7472506 DOI: 10.1080/0886022x.2020.1801467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Atrial fibrillation (AF) is common in end-stage renal disease patients. Besides the traditional risk factors, we aimed to find dialysis-specific factors for developing incident AF. Methods From March 2017 to August 2018, we retrospectively reviewed all outpatient-based prevalent hemodialysis patients in our artificial kidney room, and they were followed up until August 2019. Dialysate calcium concentration (3 versus 2.5 mEq/L), time length (4 versus 3.5 h), frequency (thrice weekly versus twice weekly), dialyzer size (effective surface area of 1.4 m2 versus 1.8 m2), membrane permeability (high flux versus low flux), ultrafiltration rate (mL/kg/hour), and blood flow rate (mL/min) were evaluated. Results Among a total of 84 patients, 15 (17.9%) had newly detected AF with a follow-up period of 21 (13.3–24) months. By performing multivariate Cox regression analysis, blood flow rate (mL/min) and ultrafiltration rate (mL/kg/h) were considered significant factors for developing incident AF (adjusted hazard ratio [HR], 0.977; p = 0.011 and adjusted HR, 1.176; p = 0.013, respectively), while dialysis bath, time length, and frequency, dialyzer size, and membrane type were not considered significant factors. Ultrafiltration cutoff rate of 8.6 mL/kg/h was the best predictive factor for incident AF (area under the curve-receiver operating characteristic [AUC-ROC], 0.746; p < 0.005), while blood flow rate was not considered a significant factor for incident AF in ROC analysis (AUC-ROC, 0.623; p = 0.126). Ultrafiltration rate was largely dependent on interdialytic weight gain (p < 0.005, linear-by-linear association). Conclusion Higher ultrafiltration rate was associated with incident AF in hemodialysis patients.
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Affiliation(s)
- Seung Don Baek
- Department of Internal Medicine, Division of Nephrology, Mediplex Sejong Hospital, Incheon, Korea
| | - Soomin Jeung
- Department of Internal Medicine, Division of Nephrology, Mediplex Sejong Hospital, Incheon, Korea
| | - Jae-Young Kang
- Department of Internal Medicine, Division of Nephrology, Sejong General Hospital, Bucheon, Korea
| | - Ki Hyun Jeon
- Department of Internal Medicine, Division of Cardiology, Mediplex Sejong Hospital, Incheon, Korea
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Kuno T, Takagi H, Ando T, Sugiyama T, Miyashita S, Valentin N, Shimada YJ, Kodaira M, Numasawa Y, Briasoulis A, Burger A, Bangalore S. Oral Anticoagulation for Patients With Atrial Fibrillation on Long-Term Dialysis. J Am Coll Cardiol 2020; 75:273-285. [DOI: 10.1016/j.jacc.2019.10.059] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/28/2019] [Accepted: 10/29/2019] [Indexed: 01/06/2023]
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Jegatheswaran J, Hundemer GL, Massicotte-Azarniouch D, Sood MM. Anticoagulation in Patients With Advanced Chronic Kidney Disease: Walking the Fine Line Between Benefit and Harm. Can J Cardiol 2019; 35:1241-1255. [PMID: 31472820 DOI: 10.1016/j.cjca.2019.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 07/03/2019] [Accepted: 07/04/2019] [Indexed: 12/23/2022] Open
Abstract
Chronic kidney disease affects more than 3 million Canadians and is highly associated with cardiovascular diseases that require anticoagulation, such as atrial fibrillation and venous thromboembolism. Patients with chronic kidney disease are at a problematic crossroads; they are at high risk of thrombotic conditions requiring anticoagulation and bleeding complications due to anticoagulation. The limited high-quality clinical evidence to guide decision-making in this area further compounds the dilemma. In this review, we discuss the physiology and epidemiology of bleeding and thrombosis in patients with kidney disease. We specifically focus on patients with advanced kidney disease (estimated glomerular filtration rate ≤ 30 mL/min) or who are receiving dialysis and focus on the nephrologist perspective regarding these issues. We summarize the existing evidence for anticoagulation use in the prevention of stroke with atrial fibrillation and provide practical clinical recommendations for considering anticoagulation use in this population. Last, we examine specific scenarios such as the use of a glomerular filtration rate estimating equation and dosing, the use of existing prediction tools for stroke and hemorrhage risk, current patterns of anticoagulation use (including during the dialysis procedure), and vascular calcification with vitamin K antagonist use in patients with chronic kidney disease.
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Affiliation(s)
| | - Gregory L Hundemer
- Division of Nephrology, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Manish M Sood
- Division of Nephrology, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; The Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
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Alshogran OY. Warfarin Dosing and Outcomes in Chronic Kidney Disease: A Closer Look at Warfarin Disposition. Curr Drug Metab 2019; 20:633-645. [PMID: 31267868 DOI: 10.2174/1389200220666190701095807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 04/02/2019] [Accepted: 06/12/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Chronic Kidney Disease (CKD) is a prevalent worldwide health problem. Patients with CKD are more prone to developing cardiovascular complications such as atrial fibrillation and stroke. This warrants the use of oral anticoagulants, such as warfarin, in this population. While the efficacy and safety of warfarin in this setting remain controversial, a growing body of evidence emphasizes that warfarin use in CKD can be problematic. This review discusses 1) warfarin use, dosing and outcomes in CKD patients; and 2) possible pharmacokinetic mechanisms for altered warfarin dosing and response in CKD. METHODS Structured search and review of literature articles evaluating warfarin dosing and outcomes in CKD. Data and information about warfarin metabolism, transport, and pharmacokinetics in CKD were also analyzed and summarized. RESULTS The literature data suggest that changes in warfarin pharmacokinetics such as protein binding, nonrenal clearance, the disposition of warfarin metabolites may partially contribute to altered warfarin dosing and response in CKD. CONCLUSION Although the evidence to support warfarin use in advanced CKD is still unclear, this synthesis of previous findings may help in improving optimized warfarin therapy in CKD settings.
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Affiliation(s)
- Osama Y Alshogran
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
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Hussain S, Siddiqui AN, Baxi H, Habib A, Hussain MS, Najmi AK. Warfarin use increases bleeding risk in hemodialysis patients with atrial fibrillation: A meta-analysis of cohort studies. J Gastroenterol Hepatol 2019; 34:975-984. [PMID: 30614083 DOI: 10.1111/jgh.14601] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 12/22/2018] [Accepted: 01/02/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND AIM Atrial fibrillation is one of the most common comorbid conditions in hemodialysis patients, and warfarin is widely prescribed anticoagulant to prevent thromboembolic complications in such patients. In the last decade, several epidemiological studies pointed out the risk of bleeding with the use of warfarin. So, this meta-analysis is aimed to assess the bleeding risk associated with the use of warfarin. METHODS This meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. PubMed, Embase, Scopus, and Cochrane central databases were searched from inception to June 10, 2018. The primary outcome was to quantify the bleeding risk associated with warfarin use. The secondary outcome was to assess the bleeding risk based on different subgroups. Review Manager (RevMan) version 5.3 was used for performing statistical analysis. RESULTS A total of 15 studies, constituting a pooled sample of 53 581 patients (37.14% female), were included. Of these, 17 469 were warfarin users. We found that warfarin use had a significant association with the bleeding risk. The pooled relative risk (RR) of bleeding was estimated to be 1.35 (95% CI: 1.18-1.53, P = < 0.00001), and the pooled RR of major bleeding (five studies) was estimated to be 1.32 (95% CI: 1.07-1.63, P = 0.009). Subgroup analysis revealed a significant association of warfarin use with the intracranial hemorrhage/hemorrhagic stroke (nine studies) (pooled RR: 1.43 [95% CI: 1.20-1.71, P = < 0.0001]). CONCLUSIONS The results indicate that warfarin use increases the risk of bleeding in hemodialysis patients with atrial fibrillation.
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Affiliation(s)
- Salman Hussain
- Department of Pharmaceutical Medicine (Division of Pharmacology), School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
| | - Ali Nasir Siddiqui
- Department of Pharmaceutical Medicine (Division of Pharmacology), School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
| | - Harveen Baxi
- Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
| | - Anwar Habib
- Department of Medicine, Hamdard Institute of Medical Sciences and Research, Jamia Hamdard, New Delhi, India
| | | | - Abul Kalam Najmi
- Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
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Lei H, Yu LT, Wang WN, Zhang SG. Warfarin and the Risk of Death, Stroke, and Major Bleeding in Patients With Atrial Fibrillation Receiving Hemodialysis: A Systematic Review and Meta-Analysis. Front Pharmacol 2018; 9:1218. [PMID: 30459610 PMCID: PMC6232383 DOI: 10.3389/fphar.2018.01218] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 10/05/2018] [Indexed: 01/11/2023] Open
Abstract
Background: Up to date, the efficacy and safety of warfarin treatment in atrial fibrillation patients receiving hemodialysis remain controversial. So we performed this meta-analysis to try to offer recommendations regarding warfarin management in this population. Methods: We searched Pubmed, Embase, and Cochrane library and reviewed relevant reference lists from 1980 to March 2018. Studies were included if they described the risks of mortality, stroke, and bleeding events with or without warfarin in atrial fibrillation patients receiving hemodialysis. Results: Overall, the use of warfarin was not associated with mortality (OR = 0.95, 95%CI = 0.89–1.02), stroke (OR = 1.06, 95% CI = 0.87–1.30) and ischemic stroke (OR = 0.85, 95% CI = 0.68–1.05), but its use could increase the risks of hemorrhagic stroke (OR = 1.34, 95% CI = 1.13–1.59) and major bleeding (OR = 1.24, 95% CI = 1.14, 1.35). In subgroup analyses, when analyses were mainly restricted to atrial fibrillation patients who were undergoing hemodialysis and taking other anticoagulation agents, warfarin therapy didn't reduce the risks for mortality (OR = 0.98, 95% CI = 0.68–1.42) and ischemic stroke (OR = 1.03, 95% CI = 0.89–1.19), but significantly increased the risks of stroke (OR:1.14, 95% CI = 1.01–1.29) and bleeding events such as hemorrhagic stroke (OR = 1.42, 95% CI = 1.14–1.77) and major bleeding (OR = 1.24, 95% CI = 1.14–1.35). While in patients who didn't take other anticoagulation agents or aspirin, warfarin use was not associated with all-cause mortality (OR = 0.90, 95% CI = 0.78–1.04), or any stroke (OR = 1.00, 95% CI = 0.71–1.40). Its use was associated with significantly decreased risk of ischemic stroke (OR = 0.71, 95% CI = 0.60–0.85), but not associated with hemorrhagic stroke (OR = 1.45, 95% CI = 0.83–2.55). Besides, another subgroup analysis showed that warfarin therapy didn't exert a protective role in patients with normal serum lipid levels (OR = 1.04, 95% CI = 0.85–1.26), but seemed to decrease the risk of ischemic stroke in patients with hyperlipidemia (OR = 0.38, 95% CI = 0.11–1.29). Conclusion: Our results suggested that it was necessary to prescribe warfarin for the prevention of ischemic events in hemodialysis patients with atrial fibrillation, but if these patients were already prescribed with other anticoagulants for the treatment of other co-existing diseases, then warfarin was not recommended.
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Affiliation(s)
- Hong Lei
- Department of Traditional Medicine Testing, Institute for Drug and Instrument Control of Beijing Military Area Command, Beijing, China
| | - Li-Ting Yu
- Department of Clinical Pharmacy, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei-Ning Wang
- Department of Traditional Medicine Testing, Institute for Drug and Instrument Control of Beijing Military Area Command, Beijing, China
| | - Shun-Guo Zhang
- Department of Clinical Pharmacy, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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20
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Ocak G, Noordzij M, Rookmaaker MB, Cases A, Couchoud C, Heaf JG, Jarraya F, De Meester J, Groothoff JW, Waldum-Grevbo BE, Palsson R, Resic H, Remón C, Finne P, Stendahl M, Verhaar MC, Massy ZA, Dekker FW, Jager KJ. Mortality due to bleeding, myocardial infarction and stroke in dialysis patients. J Thromb Haemost 2018; 16:1953-1963. [PMID: 30063819 DOI: 10.1111/jth.14254] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 07/21/2018] [Indexed: 01/13/2023]
Abstract
Essentials Mortality due to bleeding vs. arterial thrombosis in dialysis patients is unknown. We compared death causes of 201 918 dialysis patients with the general population. Dialysis was associated with increased mortality risks of bleeding and arterial thrombosis. Clinicians should be aware of the increased bleeding and thrombosis risks. SUMMARY Background Dialysis has been associated with both bleeding and thrombotic events. However, there is limited information on bleeding as a cause of death versus arterial thrombosis as a cause of death. Objectives To investigate the occurrence of bleeding, myocardial infarction and stroke as causes of death in the dialysis population as compared with the general population. Methods We included 201 918 patients from 11 countries providing data to the ERA-EDTA Registry who started dialysis treatment between 1994 and 2011, and followed them for 3 years. Age-standardized and sex-standardized mortality rate ratios for bleeding, myocardial infarction and stroke as causes of death were calculated in dialysis patients as compared with the European general population. Associations between potential risk factors and these causes of death in dialysis patients were investigated by calculating hazard ratios (HRs) with 95% confidence intervals (CIs) by the use of Cox proportional-hazards regression. Results As compared with the general population, the age-standardized and sex-standardized mortality rate ratios in dialysis patients were 12.8 (95% CI 11.9-13.7) for bleeding as a cause of death (6.2 per 1000 person-years among dialysis patients versus 0.3 per 1000 person-years in the general population), 13.4 (95% CI 13.0-13.9) for myocardial infarction (22.5 versus 0.9 per 1000 person-years), and 12.4 (95% CI 11.9-12.9) for stroke (14.3 versus 0.7 per 1000 person-years). Conclusion Dialysis patients have highly increased risks of death caused by bleeding and arterial thrombosis as compared with the general population. Clinicians should be aware of the increased mortality risks caused by these conditions.
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Affiliation(s)
- G Ocak
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - M Noordzij
- ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - M B Rookmaaker
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - A Cases
- Registre de Malalts Renals de Catalunya, Universitat de Barcelona, IDIBAPS, Barcelona, Spain
| | - C Couchoud
- REIN Registry, Agence de Biomedecine, Saint Denis La Plaine, France
| | - J G Heaf
- Department of Medicine, Zealand University Hospital, Roskilde, Denmark
| | - F Jarraya
- Department of Nephrology, Sfax University Hospital and Research Unit, Faculty of Medicine, Sfax University, Sfax, Tunisia
| | - J De Meester
- Department of Nephrology, Dialysis and Hypertension, Dutch-Speaking Belgian Renal Registry, Sint-Niklaas, Belgium
| | - J W Groothoff
- Department of Pediatric Nephrology, Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - B E Waldum-Grevbo
- Department of Nephrology, Oslo University Hospital Ullevål, Oslo, Norway
| | - R Palsson
- Division of Nephrology, Internal Medicine Services, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
- Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | - H Resic
- Clinic for Hemodialysis, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - C Remón
- SICATA (The Information System of the Andalusian Transplant Autonomic Coordination Registry), Andalusia, Spain
| | - P Finne
- Finnish Registry for Kidney Diseases, Helsinki, Finland
| | - M Stendahl
- Swedish Renal Registry, Department of Internal Medicine, Ryhov County Hospital, Jönköping, Sweden
| | - M C Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Z A Massy
- Division of Nephrology, Ambroise Paré University Hospital, APHP, Boulogne Billancourt/Paris, France
- INSERM Unit 1018, CESP, Team 5, UVSQ, Villejuif, France
| | - F W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - K J Jager
- ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
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Collins-Yoder A, Collins RE. Periprocedural Considerations for Anticoagulated Atrial Fibrillation Patients. J Perianesth Nurs 2018; 34:227-239. [PMID: 30245032 DOI: 10.1016/j.jopan.2018.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 04/17/2018] [Accepted: 05/09/2018] [Indexed: 11/19/2022]
Abstract
Periprocedural patient instruction and coordination is an important piece in achieving safe outcomes for patients needing procedures and receiving anticoagulants for atrial fibrillation. Balancing the needs for anticoagulation versus bleeding during the procedure requires clinical reasoning and preparation. In this article, the current guidelines for use of anticoagulants with atrial fibrillation, the relevant pharmacology, and the use of standardized tools to quantify the risks of thrombus or bleeding in the procedures will be discussed. In addition, resources for examining the optimal practice for these case types will be provided. Perianesthesia health care providers are pivotal to lead relevant stakeholders in the perianesthesia setting work together to create protocols and individual plans of care for this patient population.
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Mlodawska E, Lopatowska P, Malyszko J, Banach M, Sobkowicz B, Covic A, Tomaszuk-Kazberuk A. Atrial fibrillation in dialysis patients: is there a place for non-vitamin K antagonist oral anticoagulants? Int Urol Nephrol 2018; 50:1633-1642. [PMID: 29785661 DOI: 10.1007/s11255-018-1877-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 04/18/2018] [Indexed: 01/03/2023]
Abstract
Atrial fibrillation (AF) occurs approximately in 3% of general population, with greater prevalence in elderly. Non-vitamin K-dependent oral anticoagulant agents (NOACs) according to the current European guidelines are recommended for patients with AF at high risk for stroke as a first-choice treatment. NOACs are not inferior to warfarin or some of them are better than warfarin in reducing the rate of ischemic stroke. Moreover, they significantly reduce the rate of intracranial hemorrhages, major bleedings, and mortality compared with warfarin. Nevertheless according to ESC guidelines, NOACs are not recommended in patients with creatinine clearance < 30 mL/min. Observational studies provide contradictive data. Only few new trials are ongoing. Therefore, it is not clear if NOACs should be in the future prescribed to patients with advanced CKD and those on dialysis. Moreover, the risk of stroke and bleeding is much higher in such population than in patients without end-stage renal disease (ESRD). The authors provide data on pros and cons of use of NOACs in ESRD patients with AF.
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Affiliation(s)
- Elzbieta Mlodawska
- Department of Cardiology, Medical University in Bialystok, Białystok, Poland
| | - Paulina Lopatowska
- Department of Cardiology, Medical University in Bialystok, Białystok, Poland
| | - Jolanta Malyszko
- Department of Nephrology, Dialysis and Internal Medicine, Warsaw Medical University, Warsaw, Poland
| | - Maciej Banach
- Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Lodz, Poland
| | - Bożena Sobkowicz
- Department of Cardiology, Medical University in Bialystok, Białystok, Poland
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center - 'C.I. Parhon' University Hospital, and 'Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Anna Tomaszuk-Kazberuk
- Department of Cardiology, Medical University in Bialystok, Białystok, Poland. .,Department of Cardiology, University Hospital in Bialystok, ul. Skłodowskiej-Curie 24A, 15-276, Białystok, Poland.
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Reed D, Palkimas S, Hockman R, Abraham S, Le T, Maitland H. Safety and effectiveness of apixaban compared to warfarin in dialysis patients. Res Pract Thromb Haemost 2018; 2:291-298. [PMID: 30046731 PMCID: PMC6055495 DOI: 10.1002/rth2.12083] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 01/20/2018] [Indexed: 11/05/2022] Open
Abstract
Background: The use of apixaban for stroke prophylaxis or for the treatment of venous thromboembolism in end stage renal disease (ESRD) patients maintained on dialysis is based on one single-dose pharmacokinetic study. There is a deficiency of clinical evidence supporting safety in this population.Objective: The purpose of this study was to determine the safety and efficacy of apixaban compared with warfarin in dialysis patients.Patients/methods: This is a retrospective cohort study conducted at the University of Virginia Medical Center. A total of 124 ESRD patients maintained on dialysis who either received apixaban (n = 74) or warfarin (n = 50) between January 1, 2014 and October 31, 2016 were included in the study. We used multivariable logistic regression to compare the likelihood of patients experiencing a bleeding event based on anticoagulant therapy.Results: The apixaban group experienced fewer overall bleeding events than the warfarin group (18.9% vs 42.0%; P = .01); this significant difference persisted in adjusted analysis (OR = 0.15; 95% CI = 0.05-0.46; P = .001). Major bleeding events were less frequent in the apixaban group compared with patients on warfarin (5.4% vs 22.0%; P = .01). There were no recurrent ischemic strokes in either groups. A lower, non-significant, incidence of recurrent VTE was found in patients on apixaban compared with warfarin (4.4% vs 28.6%; P = .99).Conclusion: Compared to warfarin, our findings suggest that apixaban is a safe and effective alternative in patients with ESRD maintained on dialysis, with apixaban patients experiencing fewer bleeding events than warfarin patients.
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Affiliation(s)
- Daniel Reed
- Division of Hematology & OncologyUniversity of VirginiaCharlottesvilleVAUSA
| | - Surabhi Palkimas
- Department of PharmacyUniversity of VirginiaCharlottesvilleVAUSA
| | - Rebecca Hockman
- Department of PharmacyUniversity of VirginiaCharlottesvilleVAUSA
| | - Sumner Abraham
- Department of MedicineUniversity of VirginiaCharlottesvilleVAUSA
| | - Tri Le
- Division of Hematology & OncologyUniversity of VirginiaCharlottesvilleVAUSA
| | - Hillary Maitland
- Division of Hematology & OncologyUniversity of VirginiaCharlottesvilleVAUSA
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Use of oral anticoagulants in patients with atrial fibrillation and renal dysfunction. Nat Rev Nephrol 2018; 14:337-351. [PMID: 29578207 DOI: 10.1038/nrneph.2018.19] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Atrial fibrillation (AF) and chronic kidney disease (CKD) are increasingly prevalent in the general population and share common risk factors such as older age, hypertension and diabetes mellitus. The presence of CKD increases the risk of incident AF, and, likewise, AF increases the risk of CKD development and/or progression. Both conditions are associated with substantial thromboembolic risk, but patients with advanced CKD also exhibit a paradoxical increase in bleeding risk. In the landmark randomized clinical trials that compared non-vitamin K antagonist oral anticoagulants (NOACs) with warfarin for thromboprophylaxis in patients with AF, the efficacy and safety of NOACs in patients with mild-to-moderate CKD were similar to those in patients without CKD. Dose adjustment of NOACs as per the prescribing label is required in this population. Owing to limited trial data, evidence-based recommendations for the management of patients with AF and severe CKD or end-stage renal disease on dialysis are lacking. Observational cohort studies have reported conflicting results, and the management of these particularly vulnerable patients remains challenging and requires careful assessment of stroke and bleeding risk and, where appropriate, use of warfarin with good-quality anticoagulation control.
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Parker K, Mitra S, Thachil J. Is anticoagulating haemodialysis patients with non-valvular atrial fibrillation too risky? Br J Haematol 2018; 181:725-736. [PMID: 29468649 DOI: 10.1111/bjh.15144] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
There is an increasing understanding of the risks from atrial fibrillation (AF) in the current era. In patients with end-stage renal disease (ESRD) on dialysis, the prevalence of AF is significantly higher compared to the general population and those with earlier stages of CKD. Although anticoagulation of these patients may seem appropriate, there is a lack of conclusive evidence that it provides the same protection from thromboembolic complications as it does in patients not on dialysis. In addition, the increased risk of bleeding in patients requiring dialysis makes the use of anticoagulants less favourable. This article aims to discuss the problem of AF in dialysis patients, summarise the current evidence around the use of oral anticoagulants for AF in ESRD and provide some practical suggestions on management of AF in the haemodialysis population.
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Affiliation(s)
- Kathrine Parker
- Department of Pharmacy, Manchester Royal Infirmary, Manchester, UK
| | - Sandip Mitra
- Department of Renal Medicine, Manchester Institute of Nephrology and Transplantation, Manchester, UK
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
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Sánchez Soriano RM, Albero Molina MD, Chamorro Fernández CI, Juliá-Sanchís R, López Menchero R, Del Pozo Fernández C, Grau Jornet G, Núñez Villota J. Long-term prognostic impact of anticoagulation on patients with atrial fibrillation undergoing hemodialysis. Nefrologia 2018; 38:394-400. [PMID: 29426785 DOI: 10.1016/j.nefro.2017.11.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Revised: 08/16/2017] [Accepted: 11/28/2017] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION AND OBJECTIVES Evidence for the efficacy and safety of oral anticoagulation with dicumarines in patients with atrial fibrillation (AF) on hemodialysis is controversial. The aim of our study is to evaluate the long-term prognostic implications of anticoagulation with dicumarines in a cohort of patients with non-valvular AF on a hemodialysis program due to end-stage renal disease. METHODS Retrospective, observational study with consecutive inclusion of 74 patients with AF on hemodialysis. The inclusion period was from January 2005 to October 2016. The primary variables were all-cause mortality, non-scheduled readmissions and bleeding during follow-up. RESULTS Mean age was 75±10 years; 66.2% were men and 43 patients (58.1%) received acenocoumarol. During a median follow-up of 2.40 years (IQR=0.88-4.15), acenocoumarol showed no survival benefit [HR=0.76, 95% CI (0.35-1.66), p=0.494]. However, anticoagulated patients were at increased risk of recurrent cardiovascular hospitalizations [IRR=3.94, 95% CI (1.06-14.69), p=0.041]. There was a trend towards an increase in repeated hospitalizations of ischemic cause in anticoagulated patients [IRR=5.80, 95% CI (0.86-39.0), p=0.071]. There was a statistical trend towards a higher risk of recurrent total bleeding in patients treated with acenocoumarol [IRR=4.43, 95% CI (0.94-20.81), p=0.059]. CONCLUSIONS In this study, oral anticoagulation with acenocoumarol in patients with AF on hemodialysis did not increase survival. However, it was associated with an increased risk of hospitalizations of cardiovascular causes and a tendency to an increased risk of total bleeding.
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Affiliation(s)
| | | | | | - Rocío Juliá-Sanchís
- Universidad de Alicante, Facultad Ciencias de La Salud (Enfermería), Alicante, España
| | | | | | | | - Julio Núñez Villota
- Servicio de Cardiología, Hospital Clínico Universitario, INCLIVA, Universitat de València. CIBER Cardiovascular , Valencia, España
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Bansal VK, Herzog CA, Sarnak MJ, Choi MJ, Mehta R, Jaar BG, Rocco MV, Kramer H. Oral Anticoagulants to Prevent Stroke in Nonvalvular Atrial Fibrillation in Patients With CKD Stage 5D: An NKF-KDOQI Controversies Report. Am J Kidney Dis 2017; 70:859-868. [DOI: 10.1053/j.ajkd.2017.08.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 08/08/2017] [Indexed: 12/17/2022]
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Affiliation(s)
- Charmaine E Lok
- Division of Nephrology, Department of Medicine, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
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Harel Z, Chertow GM, Shah PS, Harel S, Dorian P, Yan AT, Saposnik G, Sood MM, Molnar AO, Perl J, Wald RM, Silver S, Wald R. Warfarin and the Risk of Stroke and Bleeding in Patients With Atrial Fibrillation Receiving Dialysis: A Systematic Review and Meta-analysis. Can J Cardiol 2017; 33:737-746. [DOI: 10.1016/j.cjca.2017.02.004] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 02/06/2017] [Accepted: 02/07/2017] [Indexed: 01/11/2023] Open
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Vitamin K antagonists for stroke prevention in hemodialysis patients with atrial fibrillation: A systematic review and meta-analysis. Am Heart J 2017; 184:37-46. [PMID: 27892885 DOI: 10.1016/j.ahj.2016.09.016] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 09/23/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND The use of vitamin K antagonists (VKAs) in hemodialysis patients with atrial fibrillation (AF) is controversial. No randomized trials are available and observational studies have yielded conflicting results, engendering a large clinical practice variability and physician uncertainty. An unresolved but highly relevant question is whether AF poses a true risk of ischemic stroke in hemodialysis and whether any form of oral anticoagulation is therefore warranted. METHODS We conducted a systematic review of studies that compared the incidence of ischemic stroke and bleeding in hemodialysis patients with AF taking VKA and those not taking VKA. When hemodialysis patients had been pooled with peritoneal dialysis, kidney transplant, or stage V chronic kidney disease patients, unpublished outcome data of the hemodialysis subgroup were obtained through personal communication. The main outcome measures were ischemic stroke/thromboembolic events, all-cause mortality, major bleeding, and hemorrhagic stroke. Combined hazard ratios (HRs) and 95% CIs were calculated using a random-effects model. RESULTS Twelve prospective or retrospective cohort studies were included in the meta-analysis, totaling 17,380 hemodialysis patients of whom 4,010 (23.1%) received VKA. In VKA-treated patients, mean CHADS2 or CHA2DS2VASc score was low (range 1.7-2.75) or a sizeable proportion of patients had scores <2 (range 2%-23%). Time in the therapeutic range or mean international normalized ratio was generally low. Treatment with VKA was associated with a nonsignificant 26% reduction of the risk of ischemic stroke (HR 0.74; 0.51-1.06), a 21% increase in total bleeding risk (HR 1.21; 1.03-1.43), and no effect on mortality (HR 1.00; 0.92-1.09). Vitamin K antagonist almost doubled the risk of hemorrhagic stroke, but this did not reach the limit of statistical significance (4 studies, n = 16.365; HR 1.93; 0.93-3.98). CONCLUSION Our meta-analysis revealed a trend for a reduction of the risk of ischemic stroke in hemodialysis patients with AF treated with VKA. The true protective effect may have been underestimated, owing to inclusion of low-risk patients not expected to benefit from anticoagulation and to suboptimal anticoagulation. However, assessment of the overall effect of VKA in hemodialysis patients should also take into account the increased risk of bleeding, in particular of hemorrhagic stroke. Whether new oral anticoagulants provide a better benefit-risk ratio in hemodialysis patients should be the subject of future trials.
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McCullough PA, Ball T, Cox KM, Assar MD. Use of Oral Anticoagulation in the Management of Atrial Fibrillation in Patients with ESRD: Pro. Clin J Am Soc Nephrol 2016; 11:2079-2084. [PMID: 27797888 PMCID: PMC5108189 DOI: 10.2215/cjn.02680316] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Warfarin has had a thin margin of benefit over risk for the prevention of stroke and systemic embolism in patients with ESRD because of higher bleeding risks and complications of therapy. The successful use of warfarin has been dependent on the selection of patients with nonvalvular atrial fibrillation at relatively high risk of stroke and systemic embolism and lower risks of bleeding over the course of therapy. Without such selection strategies, broad use of warfarin has not proven to be beneficial to the broad population of patients with ESRD and nonvalvular atrial fibrillation. In a recent meta-analysis of use of warfarin in patients with nonvalvular atrial fibrillation and ESRD, warfarin had no effect on the risks of stroke (hazard ratio, 1.12; 95% confidence interval, 0.69 to 1.82; P=0.65) or mortality (hazard ratio, 0.96; 95% confidence interval, 0.81 to 1.13; P=0.60) but was associated with increased risk of major bleeding (hazard ratio, 1.30; 95% confidence interval, 1.08 to 1.56; P<0.01). In pivotal trials, novel oral anticoagulants were generally at least equal to warfarin for efficacy and safety in nonvalvular atrial fibrillation and mild to moderate renal impairment. Clinical data for ESRD are limited, because pivotal trials excluded such patients. Given the very high risk of stroke and systemic embolism and the early evidence of acceptable safety profiles of novel oral anticoagulants, we think that patients with ESRD should be considered for treatment with chronic anticoagulation provided that there is an acceptable bleeding profile. Apixaban is currently indicated in ESRD for this application and may be preferable to warfarin given the body of evidence for warfarin and its difficulty of use and attendant adverse events.
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Affiliation(s)
- Peter A. McCullough
- Department of Internal Medicine, Cardiology Division, Baylor University Medical Center, Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas
- The Heart Hospital Baylor Plano, Plano, Texas; and
| | - Timothy Ball
- Department of Internal Medicine, Cardiology Division, Baylor University Medical Center, Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas
| | - Katy Mathews Cox
- Department of Clinical Pharmacology, Baylor University Medical Center, Dallas, Texas
| | - Manish D. Assar
- Department of Internal Medicine, Cardiology Division, Baylor University Medical Center, Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas
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Tan J, Liu S, Segal JB, Alexander GC, McAdams-DeMarco M. Warfarin use and stroke, bleeding and mortality risk in patients with end stage renal disease and atrial fibrillation: a systematic review and meta-analysis. BMC Nephrol 2016; 17:157. [PMID: 27769175 PMCID: PMC5073415 DOI: 10.1186/s12882-016-0368-6] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 10/11/2016] [Indexed: 12/15/2022] Open
Abstract
Background Patients with end stage renal disease (ESRD), including stage 5 chronic kidney disease (CKD), hemodialysis (HD) and peritoneal dialysis (PD), are at high risk for stroke-related morbidity, mortality and bleeding. The overall risk/benefit balance of warfarin treatment among patients with ESRD and AF remains unclear. Methods We systematically reviewed the associations of warfarin use and stroke outcome, bleeding outcome or mortality in patients with ESRD and AF. We conducted a comprehensive literature search in Feb 2016 using key words related to ESRD, AF and warfarin in PubMed, Embase and Cochrane Library without language restriction. We searched for randomized trials and observational studies that compared the use of warfarin with no treatment, aspirin or direct oral anticoagulants (DOACs), and reported quantitative risk estimates on these outcomes. Paired reviewers screened articles, collected data and performed qualitative assessment using the Cochrane Risk of Bias Assessment Tool for Non-randomized Studies of Interventions. We conducted meta-analyses using the random-effects model with the DerSimonian - Laird estimator and the Knapp-Hartung methods as appropriate. Results We identified 2709 references and included 20 observational cohort studies that examined stroke outcome, bleeding outcome and mortality associated with warfarin use in 56,146 patients with ESRD and AF. The pooled estimates from meta-analysis for the stroke outcome suggested that warfarin use was not associated with all-cause stroke (HR = 0.92, 95 % CI 0.74–1.16) or any stroke (HR = 1.01, 95 % CI 0.81–1.26), or ischemic stroke (HR = 0.80, 95 % CI 0.58–1.11) among patients with ESRD and AF. In contrast, warfarin use was associated with significantly increased risk of all-cause bleeding (HR = 1.21, 95 % CI 1.01–1.44), but not associated with major bleeding (HR = 1.18, 95 % CI 0.82–1.69) or gastrointestinal bleeding (HR = 1.19, 95 % CI 0.81–1.76) or any bleeding (HR = 1.21, 95 % CI 0.99–1.48). There was insufficient evidence to evaluate the association between warfarin use and mortality in this population (pooled risk estimate not calculated due to high heterogeneity). Results on DOACs were inconclusive due to limited relevant studies. Conclusions Given the absence of efficacy and an increased bleeding risk, these findings call into question the use of warfarin for AF treatment among patients with ESRD.
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Affiliation(s)
- Jingwen Tan
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD, 21205, USA.,Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Shuiqing Liu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD, 21205, USA
| | - Jodi B Segal
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD, 21205, USA.,Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - G Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD, 21205, USA.,Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Mara McAdams-DeMarco
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD, 21205, USA. .,Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. .,Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
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Nochaiwong S, Ruengorn C, Awiphan R, Dandecha P, Noppakun K, Phrommintikul A. Efficacy and safety of warfarin in dialysis patients with atrial fibrillation: a systematic review and meta-analysis. Open Heart 2016; 3:e000441. [PMID: 27386140 PMCID: PMC4916629 DOI: 10.1136/openhrt-2016-000441] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Revised: 04/23/2016] [Accepted: 05/09/2016] [Indexed: 02/07/2023] Open
Abstract
Objective To systematically review and meta-analyse the risk–benefit ratio of warfarin users compared with non-warfarin users in patients with atrial fibrillation (AF), who are undergoing dialysis. Methods We searched PubMed/MEDLINE, EMBASE, SCOPUS, Web of Science, Cochrane Library, grey literature, conference proceedings, trial registrations and also did handsearch. Cohort studies without language restrictions were included. Two investigators independently conducted a full abstraction of data, risk of bias and graded evidence. Effect estimates were pooled using random-effect models. Main outcome measure All-cause mortality, total stroke/thromboembolism and bleeding complications. Results 14 studies included 37 349 dialysis patients with AF, of whom 12 529 (33.5%) were warfarin users. For all-cause mortality: adjusted HR=0.99 (95% CI 0.89 to 1.10; p=0.825), unadjusted risk ratio (RR)=1.00 (95% CI 0.96 to 1.04; p=0.847). For stroke/thromboembolism: adjusted HR=1.06 (95% CI 0.82 to 1.36; p=0.676), unadjusted incidence rate ratio (IRR)=1.23 (95% CI 0.94 to 1.61; p=0.133). For ischaemic stroke/transient ischaemic attack, adjusted HR=0.91 (95% CI 0.57 to 1.45; p=0.698), unadjusted IRR=1.16 (95% CI 0.84 to 1.62; p=0.370). For haemorrhagic stroke, adjusted HR=1.60 (95% CI 0.91 to 2.81; p=0.100), unadjusted IRR=1.48 (95% CI 0.92 to 2.36; p=0.102). Major bleeding was increased among warfarin users; adjusted HR=1.35 (95% CI 1.11 to 1.64; p=0.003) and unadjusted IRR=1.22 (95% CI 1.07 to 1.40; p=0.003). Conclusions Among dialysis patients with AF, warfarin therapy was not associated with mortality and stroke/thromboembolism, but significantly increased the risk of major bleeding. More rigorous studies are essential to demonstrate the effect of warfarin for stroke prophylaxis in dialysis patients with AF.
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Affiliation(s)
- Surapon Nochaiwong
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand; Pharmacoepidemiology and Statistics Clinic, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Chidchanok Ruengorn
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand; Pharmacoepidemiology and Statistics Clinic, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Rattanaporn Awiphan
- Department of Pharmaceutical Care, Faculty of Pharmacy , Chiang Mai University , Chiang Mai , Thailand
| | - Phongsak Dandecha
- Division of Nephrology, Department of Internal Medicine , Prince of Songkla University , Hat Yai, Songkhla , Thailand
| | - Kajohnsak Noppakun
- Renal Division, Department of Internal Medicine, Faculty of Medicine , Chiang Mai University , Chiang Mai , Thailand
| | - Arintaya Phrommintikul
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine , Chiang Mai University , Chiang Mai , Thailand
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Fauchier L, Chaize G, Gaudin AF, Vainchtock A, Rushton-Smith SK, Cotté FE. Predictive ability of HAS-BLED, HEMORR2HAGES, and ATRIA bleeding risk scores in patients with atrial fibrillation. A French nationwide cross-sectional study. Int J Cardiol 2016; 217:85-91. [PMID: 27179213 DOI: 10.1016/j.ijcard.2016.04.173] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 04/15/2016] [Accepted: 04/30/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The HAS-BLED, ATRIA, and HEMORR2HAGES risk scores were created to evaluate individual bleeding risk in atrial fibrillation (AF). We sought to estimate and compare the predictive ability of these scores for major hemorrhage in AF, including elderly (≥80years) and non-elderly (<80years) patients. METHODS This cross-sectional study is based on the French National Hospital Database (PMSI), which covers the entire French population. Data from all patients with an AF diagnosis in 2012 were extracted. Demographic and comorbidity data were used to calculate the three bleeding risk scores for each patient. Patients hospitalized with a principal diagnosis of major bleeding were identified. RESULTS Of the 533,044 AF patients identified, 53.2% were ≥80years; 7013 patients (1.3%) were hospitalized for a bleeding event (1785 for intracranial hemorrhage). Bleeding occurred more frequently in patients with higher HAS-BLED, HEMORR2HAGES, and ATRIA scores. In patients ≥80years, the c-statistics did not differ (p=0.27) between HAS-BLED (0.54; 95% confidence interval [CI]: 0.53-0.54), HEMORR2HAGES (0.53; 95% CI: 0.53-0.54), and ATRIA (0.53; 95% CI: 0.52-0.54). In patients <80years, HAS-BLED (0.59; 95% CI: 0.58-0.60) had a slightly higher c-statistic than HEMORR2HAGES (0.56; 95% CI: 0.55-0.57) and ATRIA (0.55, 95% CI: 0.55-0.56) (p<0.0001). CONCLUSIONS Given its simplicity and similar performance, HAS-BLED may be an attractive alternative to HEMORR2HAGES for estimation of bleeding risk in AF patients <80years. However, accurate determination of bleeding risk among the elderly is difficult with existing risk-prediction scores, indicating a clear need for improvement in their clinical utility.
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Affiliation(s)
- Laurent Fauchier
- Service de Cardiologie et Laboratoire d'Electrophysiologie Cardiaque, Pôle Cœur Thorax Vasculaire, Centre Hospitalier Universitaire Trousseau, Tours 37044, France; Faculté de Médecine, Université François Rabelais, Tours 37032, France.
| | | | | | | | - Sophie K Rushton-Smith
- Center for Outcomes Research, University of Massachusetts Medical School, Worcester, MA, USA
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Clinical characteristics and outcomes of dialysis patients with atrial fibrillation: the Fushimi AF Registry. Heart Vessels 2016; 31:2025-2034. [DOI: 10.1007/s00380-016-0818-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 02/19/2016] [Indexed: 12/17/2022]
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Cavallari LH, Mason DL. Cardiovascular Pharmacogenomics--Implications for Patients With CKD. Adv Chronic Kidney Dis 2016; 23:82-90. [PMID: 26979147 DOI: 10.1053/j.ackd.2015.12.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 12/04/2015] [Accepted: 12/08/2015] [Indexed: 01/20/2023]
Abstract
CKD is an independent risk factor for cardiovascular disease (CVD). Thus, patients with CKD often require treatment with cardiovascular drugs, such as antiplatelet, antihypertensive, anticoagulant, and lipid-lowering agents. There is significant interpatient variability in response to cardiovascular therapies, which contributes to risk for treatment failure or adverse drug effects. Pharmacogenomics offers the potential to optimize cardiovascular pharmacotherapy and improve outcomes in patients with CVD, although data in patients with concomitant CKD are limited. The drugs with the most pharmacogenomic evidence are warfarin, clopidogrel, and statins. There are also accumulating data for genetic contributions to β-blocker response. Guidelines are now available to assist with applying pharmacogenetic test results to optimize warfarin dosing, selection of antiplatelet therapy after percutaneous coronary intervention, and prediction of risk for statin-induced myopathy. Clinical data, such as age, body size, and kidney function have long been used to optimize drug prescribing. An increasing number of institutions are also implementing genetic testing to be considered in the context of important clinical factors to further personalize drug therapy for patients with CVD.
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