Low-dose aspirin for prevention of cardiovascular disease in patients on hemodialysis: A 5-y prospective cohort study

Should I Take Aspirin? (SITA): randomised controlled trial of a decision aid for cancer chemoprevention

BACKGROUND

Australian guidelines recommend that people aged 50-70 years consider taking low-dose aspirin to reduce their risk of colorectal cancer (CRC).

AIM

To determine the effect of a consultation with a researcher before an appointment in general practice using a decision aid presenting the benefits and harms of taking low-dose aspirin compared with a general CRC prevention brochure on patients' informed decision making and low-dose aspirin use.

DESIGN AND SETTING

Individually randomised controlled trial in six general practices in Victoria, Australia, from October 2020 to March 2021.

METHOD

Participants were recruited from a consecutive sample of patients aged 50-70 years attending a GP. The intervention was a consultation using a decision aid to discuss taking aspirin to reduce CRC risk while control consultations discussed reducing CRC risk generally. Self-reported co-primary outcomes were the proportion of individuals making informed choices about taking aspirin at 1 month and on low-dose aspirin uptake at 6 months, respectively. The intervention effect was estimated using a generalised linear model and reported with Bonferroni-adjusted 95% confidence intervals (CIs) and P-values.

RESULTS

A total of 261 participants (86% of eligible patients) were randomised into trial arms (n = 129 intervention; n = 132 control). Of these participants, 17.7% (n = 20/113) in the intervention group and 7.6% (n = 9/118) in the control group reported making an informed choice about taking aspirin at 1 month, an estimated 9.1% (95% CI = 0.29 to 18.5) between-arm difference in proportions (odds ratio [OR] 2.47, 97.5% CI = 0.94 to 6.52, P = 0.074). The proportions of individuals who reported taking aspirin at 6 months were 10.2% (n = 12/118) of the intervention group versus 13.8% (n = 16/116) of the control group, an estimated between-arm difference of -4.0% (95% CI = -13.5 to 5.5; OR 0.68 [97.5% CI = 0.27 to 1.70, P = 0.692]).

CONCLUSION

The decision aid improved informed decision making but this did not translate into long-term regular use of aspirin to reduce CRC risk. In future research, decision aids should be delivered alongside various implementation strategies.

Platelet Abnormalities in CKD and Their Implications for Antiplatelet Therapy

Patients with CKD display a significantly higher risk of cardiovascular and thromboembolic complications, with around half of patients with advanced CKD ultimately dying of cardiovascular disease. Paradoxically, these patients also have a higher risk of hemorrhages, greatly complicating patient therapy. Platelets are central to hemostasis, and altered platelet function resulting in either platelet hyper- or hyporeactivity may contribute to thrombotic or hemorrhagic complications. Different molecular changes have been identified that may underlie altered platelet activity and hemostasis in CKD. In this study, we summarize the knowledge on CKD-induced aberrations in hemostasis, with a special focus on platelet abnormalities. We also discuss how prominent alterations in vascular integrity, coagulation, and red blood cell count in CKD may contribute to altered hemostasis in these patients who are high risk. Furthermore, with patients with CKD commonly receiving antiplatelet therapy to prevent secondary atherothrombotic complications, we discuss antiplatelet treatment strategies and their risk versus benefit in terms of thrombosis prevention, bleeding, and clinical outcome depending on CKD stage. This reveals a careful consideration of benefits versus risks of antiplatelet therapy in patients with CKD, balancing thrombotic versus bleeding risk. Nonetheless, despite antiplatelet therapy, patients with CKD remain at high cardiovascular risk. Thus, deep insights into altered platelet activity in CKD and underlying mechanisms are important for the optimization and development of current and novel antiplatelet treatment strategies, specifically tailored to these patients who are high risk. Ultimately, this review underlines the importance of a closer investigation of altered platelet function, hemostasis, and antiplatelet therapy in patients with CKD.

Expert consensus on the establishment and maintenance of native arteriovenous fistula

Vascular access is the lifeline of hemodialysis patients. There are great differences in the establishment and use of vascular access in different countries and regions around the world. We believe that on the basis of good evaluation and planning, it is recommended that hemodialysis patients choose native arteriovenous fistula first. In view of the new progress of vascular access views domestic and international at home and abroad in recent years, we organized experts to recommend the establishment and maintenance of arteriovenous fistula (AVF) for the Chinese population, including preoperative evaluation and planning of the establishment of AVF, AVF surgery, perioperative drug intervention measures and postoperative maintenance, and put forward suggestions for future research directions. The recommendations in this consensus are general and clinicians need to make treatment decisions based on the actual situation.

The risk of non-steroidal anti-inflammatory drug-induced heart failure in people with chronic kidney disease: a systematic review

Aim

To examine the risk of non-steroidal anti-inflammatory drug-induced heart failure in patients with chronic kidney disease.

Methods

Embase, Medline, CENTRAL, Web of Science, and Google Scholar were searched for papers published in English between 1st January 1999 and 31st May 2020. Papers were included if some participants had chronic kidney disease, were exposed to non-steroidal anti-inflammatory drugs, and where heart failure was measured as an outcome. Papers were assessed for risk of bias using the Cochrane Risk of Bias 2 tool for randomised controlled trials, and ROBINS-I for observational studies.

Results

A total of 2480 independent papers were retrieved. Following abstract screening, 165 full texts were reviewed to identify seven eligible papers: two randomised controlled trials, four cohort studies, and one case-control study. For chronic kidney disease (stage 3–5), relative risk for heart failure ranged from 0.3 to 1.9 with 95% confidence interval 0.04 to 15.1. Results were not pooled due to study heterogeneity. We attributed bias to heterogenous populations studied, probable confounding due to partially adjusted risk estimates, and heterogenous measurement of the heart failure outcome.

Conclusion

Overall, there are only a few studies to refute or support an increased risk of heart failure associated with taking non-steroidal anti-inflammatory drugs in patients with chronic kidney disease, and therefore no robust evidence was available.

The risk of bleeding for antiplatelet agents in Haemodialysis patients: a Meta-analysis

Background

The safety of antiplatelet therapy in haemodialysis (HD) patients remains controversial. we conducted the first meta-analysis to evaluate the bleeding risk with antiplatelet agents in these populations.

Methods

The relevant literature was searched using the following electronic databases without any language restrictions: the Cochrane Library, EMBASE, Global Health, MEDLINE, PubMed, and the Chinese Biomedical Database.

Results

Seven randomized controlled trials (RCTs) and 2 prospective cohort studies, consisting of 1131 patients, were identified for detailed evaluation. The meta-analysis suggested that the use of double antiplatelet agents increased the risk of bleeding in HD patients [odds ratio (OR) = 2.78; 95% confidence interval (CI) 1.63 to 4.76; I² = 0], and antiplatelet agents increased the risk of bleeding in 7 RCTs [odds ratio (RR) = 1.40, 95% CI 1.08 to 1.79; I² = 23%,]; however, the use of a single antiplatelet agent was not found to significantly increase the risk of bleeding (RR = 0.88; 95% CI 0.51 to 1.50; I² = 0).

Conclusion

The results suggested that the use of double antiplatelet agents increased the risk of bleeding in HD patients.

Is there a cardiovascular protective effect of aspirin in chronic kidney disease patients? A systematic review and meta-analysis

PURPOSE

To perform a systematic review and meta-analysis to evaluate the cardiovascular prevention effect of aspirin among patients with chronic kidney disease (CKD).

METHODS

A comprehensive literature search was conducted in Embase, PubMed, and Cochrane library (up to March 2019) without language limitations. Randomized control trials (RCT) and observational studies that met the inclusion and exclusion criteria were included. Two reviewers independently extracted data, and evaluated study quality using modified Jadad score for RCTs and Newcastle-Ottawa Scale for observational study. A meta-analysis was conducted in the Stata 15.0 software using the DerSimonian and Laird random-effects model.

RESULTS

1768 references were identified from literature searching. Four RCTs and four cohort studies that reported the cardiovascular prevention outcome of aspirin in CKD patients (38,341 participants) were included in this review. The pooled data revealed that aspirin had no significant prevention effect on cardiovascular events among CKD patients (RR = 0.96, 95% CI, 0.59-1.13). There was also no significant reduction in cardiovascular mortality and all-cause mortality. Although we found no significant increased risk in major bleeding events, there was a statistically significant increased risk of minor bleeding events (RR = 2.57, 95% CI, 1.60-4.13) and renal events (RR = 1.30, 95% CI, 1.02-1.65) for aspirin use.

CONCLUSION

Our review indicated that aspirin use in CKD patients had no prevention effect on cardiovascular events and no statistically significant reduction in risk of cardiovascular or all-cause mortality, with a significant increased risk of minor bleeding and renal events.

Reduction of intracerebral hemorrhage in hemodialysis patients after reducing aspirin use: A quality-assurance observational study

There is so far no international consensus concerning the prescription of antithrombotic agents in hemodialysis patients. It is not clear yet why they cause more bleeding in some patients and are beneficial in others. We therefore tried to find out what triggers bleeding in this population. This is an observational before-and-after study that included all patients undergoing hemodialysis in our center between 2005 and 2015. We divided the study into two phases: phase one (125 patients) where aspirin was used without restrictions and phase two (110 patients) where aspirin was avoided in severe hypertension and primary prevention. We aimed to assess the differential occurrence of intracerebral hemorrhage between the two phases and the cardiovascular mortality of patients whether on aspirin or not. Bleeding events occurred in 12.8% of patients in phase one and 13.6% in phase two (p = 0.85). Seven out of 125 patients (6%) in phase one experienced intracerebral hemorrhage and none in phase two. Intracerebral hemorrhage was significantly increased in those with the combination of aspirin and severe hypertension (p = 0.003). Aspirin and acenocoumadin were significantly associated with total bleeding (OR = 3.81 and 4.85 with p = 0.005 and 0.001 respectively). Cardiovascular mortality did not differ between phase one and two whether patients were on aspirin or not (p = 0.45 and 0.31 respectively). Minimizing aspirin use in hemodialysis patients with severe hypertension reduced intracerebral bleeding without a significant difference in cardiovascular mortality.