Anticoagulation in Patients with End-Stage Renal Disease and Atrial Fibrillation: Confusion, Concerns and Consequences

When anticoagulation management in atrial fibrillation becomes difficult: Focus on chronic kidney disease, coagulation disorders, and cancer

Anticoagulation therapy (AT) is fundamental in atrial fibrillation (AF) treatment but poses challenges in implementation, especially in AF populations with elevated thromboembolic and bleeding risks. Current guidelines emphasize the need to estimate and balance thrombosis and bleeding risks for all potential candidates of antithrombotic therapy. However, administering oral AT raises concerns in specific populations, such as those with chronic kidney disease (CKD), coagulation disorders, and cancer due to lack of robust data. These groups, excluded from large direct oral anticoagulants trials, rely on observational studies, prompting physicians to adopt individualized management strategies based on case-specific evaluations. The scarcity of evidence and specific guidelines underline the need for a tailored approach, emphasizing regular reassessment of risk factors and anticoagulation drug doses. This narrative review aims to summarize evidence and recommendations for challenging AF clinical scenarios, particularly in the long-term management of AT for patients with CKD, coagulation disorders, and cancer.

Cerebrovascular Disease Hospitalization Rates in End-Stage Kidney Disease Patients with Kidney Transplant and Peripheral Vascular Disease: Analysis Using the National Inpatient Sample (2005-2019)

Individuals with end-stage kidney disease (ESKD) face higher cerebrovascular risk. Yet, the impact of peripheral vascular disease (PVD) and kidney transplantation (KTx) on hospitalization rates for cerebral infarction and hemorrhage remains underexplored. Analyzing 2,713,194 ESKD hospitalizations (2005-2019) using the National Inpatient Sample, we investigated hospitalization rates for ischemic and hemorrhagic cerebrovascular diseases concerning ESKD, PVD, KTx, or their combinations. Patients hospitalized with cerebral infarction due to thrombosis/embolism/occlusion (CITO) or artery occlusion resulting in cerebral ischemia (AOSI) had higher rates of comorbid ESKD and PVD (4.17% and 7.29%, respectively) versus non-CITO or AOSI hospitalizations (2.34%, p < 0.001; 2.29%, p < 0.001). Conversely, patients hospitalized with nontraumatic intracranial hemorrhage (NIH) had significantly lower rates of ESKD and PVD (1.64%) compared to non-NIH hospitalizations (2.34%, p < 0.001). Furthermore, hospitalizations for CITO or AOSI exhibited higher rates of KTx and PVD (0.17%, 0.09%, respectively) compared to non-CITO or AOSI hospitalizations (0.05%, p = 0.033; 0.05%, p = 0.002). Patients hospitalized with NIH showed similar rates of KTx and PVD (0.04%) versus non-NIH hospitalizations (0.05%, p = 0.34). This nationwide analysis reveals that PVD in ESKD patients is associated with increased hospitalization rates with cerebral ischemic events and reduced NIH events. Among KTx recipients, PVD correlated with increased hospitalizations for ischemic events, without affecting NIH. This highlights management concerns for patients with KTx and PVD.

Apixaban reduces the risk of major and clinically relevant non-major bleeding compared to warfarin in patients with end stage renal disease; a systematic review and meta-analysis of ten studies

Optimal anticoagulation in patients with end-stage renal disease ESRD is a matter of debate since these patients are not included in randomized controlled trials (RCTs). Evolving data are in favor of apixaban compared to warfarin.

METHODS

We extracted data from 2 RCTs, 5 retrospective cohort studies and 3 large data-based studies. Both dosing regimens of apixaban, standard or reduced, were accepted. In most studies characteristics of patients were balanced between arms. Patients with either atrial fibrillation (AF) or venous thromboembolism (VTE) were included. Quality of studies was graded as high and the funnel plot did not detect any publication bias. In total we analyzed the outcome of 6693 ESRD patients treated with apixaban and 19,836 treated with warfarin. Our analysis was performed by using the random effects model. We report our data as Risk Ratio (RR) and associated 95 % confidence interval values (95 %, CI).

RESULTS

The RR (95 % CI) of major bleeding was 0.69 (0.57-0.84) p = 0.0002 in favor of apixaban vs warfarin with heterogeneity to be statistically significant I2 63% p = 0.004. Meta-regression analysis with year of publication as moderator shows in bubble plotting that studies published earlier than 2018 were plotted as outliers. The RR (95 % CI) of clinically relevant non-major bleeding (CRNMB) was 0.74 (0.64-0.87) p = 0.0002 favoring again apixaban. Standard apixaban dose over reduced dose is less hemorrhagic compared to warfarin. Overall, in our study the risk of thrombosis in both arms was statistically non-different.

CONCLUSIONS

In our study we observed less hemorrhagic events with apixaban in ESRD patients compared to warfarin.

The safety and efficacy of direct oral anticoagulants among chronic kidney disease patients on dialysis with non-valvular atrial fibrillation: a meta-analysis

Background

Individuals with chronic kidney disease (CKD) on dialysis are at an increased risk of stroke and embolic events especially in the presence of atrial fibrillation (AF). Vitamin K antagonists (VKA), including warfarin, have been used for decades for anticoagulation among CKD patients on dialysis with AF but recent evidence has shown increased bleeding. Direct oral anticoagulants (DOAC) have been emerging as an alternative to VKA which, based on several observational cohort studies, are at least as efficacious and safe as VKA. This meta-analysis looked into the safety and efficacy of DOACs compared to VKA among CKD patients on dialysis with non-valvular AF.

Methodology

This study used a random-effects meta-analysis using RevMan 5.4. PubMed, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov were searched from their dates of inception to June 2023. The risk of bias was assessed using Cochrane RoB2 and the certainty of evidence was assessed using GRADE.

Results

This meta-analysis showed that DOACs when compared to VKA have no significant difference in terms of risk for major bleeding (RR = 0.81, 95% CI 0.46-1.43), ischemic stroke (RR = 0.5, 95% CI 0.19-1.35), and cardiovascular death (RR = 1.34, 95% CI 0.69-2.60).

Discussion

This meta-analysis adds to the growing body of evidence supporting that the use of DOACs has similar efficacy and safety outcomes in CKD patients on dialysis with non-valvular AF patients compared to VKA. The findings need to be replicated in larger and more adequately powered clinical trials in order to ascertain its level of evidence.

Choosing the right chronic medication for hemodialysis patients. A short ABC for the dialysis nephrologist

BACKGROUND

Adapting drug treatments for patients on hemodialysis with multiple chronic pathologies is a complex affair. When prescribing a medication, the risk-benefit analysis usually focuses primarily on the indication of the drug class prescribed. However, the pharmacokinetics of the chosen drug should also be taken into account. The purpose of our review was to identify the drugs to be favored in each therapeutic class, according to their safety and pharmacokinetic profiles, for the most common chronic diseases in patients on chronic hemodialysis.

METHODS

We conducted a narrative review of the literature using Medline and Web of Science databases, targeting studies on the most commonly-prescribed drugs for non-communicable diseases in patients on chronic hemodialysis.

RESULTS

The search identified 1224 articles, 95 of which were further analyzed. The main classes of drugs included concern the cardiovascular system (anti-hypertensives, anti-arrhythmics, anti-thrombotics, hypocholesterolemics), the endocrine and metabolic pathways (anti-diabetics, gastric anti-secretory, anticoagulant, thyroid hormones, anti-gout) and psychiatric and neurological disorders (antidepressants, anxiolytics, antipsychotics and anti-epileptics).

CONCLUSION

We report on the most often prescribed drugs for chronic pathologies in patients on chronic hemodialysis. Most of them require adaptation, and in some cases one better alternative stands out among the drug class. More pharmacokinetic data are needed to define the pharmacokinetics in the various dialysis techniques.

Use of non-vitamin K antagonists oral anticoagulants in atrial fibrillation patients on dialysis

Background

Non-vitamin K antagonist oral anticoagulants (NOACs) showed a benefit-risk profile superior to that of warfarin in atrial fibrillation (AF) patients with mild to moderate chronic kidney disease. However, the effectiveness and safety of NOACs in AF patients with end-stage renal disease (ESRD) on dialysis remain unclear. Therefore, we performed a meta-analysis regarding the effect of NOACs vs. warfarin in AF patients undergoing dialysis.

Methods

A search of the Pubmed and EMBASE databases until November 2021 was performed. Adjusted risk ratios (RRs) and 95%confidence intervals (CIs) were pooled by a random-effects model with an inverse variance method.

Results

Six studies involving 3,744 NOAC- and 26,973 warfarin- users were deemed to meet the criteria. In the pooled analysis, the use of mixed NOACs had similar incidences of effectiveness and safety outcomes compared with warfarin use. And factor Xa inhibitors (rivaroxaban or apixaban) did not have significantly better effectiveness than warfarin. For the safety outcomes, the use of factor Xa inhibitors was associated with a reduced risk of gastrointestinal bleeding (RR = 0.81, 95% CI 0.70–0.95), but not major bleeding and intracranial bleeding.

Conclusion

Compared with warfarin, the use of NOACs, especially factor Xa inhibitors (rivaroxaban or apixaban), showed at least similar effectiveness and safety outcomes in AF patients on dialysis.

Chronic kidney disease and risks of adverse clinical events in patients with atrial fibrillation

BACKGROUND

Chronic kidney disease (CKD) is highly prevalent in patients with atrial fibrillation (AF). However, the association between CKD and clinical consequences in AF patients is still under debate.

METHODS

We included 19,079 nonvalvular AF patients with available estimated glomerular filtration rate (eGFR) values in the Chinese Atrial Fibrillation Registry from 2011 to 2018. Patients were classified into no CKD (eGFR ≥ 90 mL/min per 1.73 m²), mild CKD (60 ≤ eGFR < 90 mL/min per 1.73 m ²), moderate CKD (30 ≤ eGFR < 60 mL/min per 1.73 m ²), and severe CKD (eGFR < 30 mL/min per 1.73 m ²) groups. The risks of thromboembolism, major bleeding, and cardiovascular mortality were estimated with Fine-Gray regression analysis according to CKD status. Cox regression was performed to assess the risk of all-cause mortality associated with CKD.

RESULTS

Over a mean follow-up of 4.1 ± 1.9 years, there were 985 thromboembolic events, 414 major bleeding events, 956 cardiovascular deaths, and 1,786 all-cause deaths. After multivariate adjustment, CKD was not an independent risk factor of thromboembolic events. As compared to patients with no CKD, those with mild CKD, moderate CKD, and severe CKD had a 45%, 47%, and 133% higher risk of major bleeding, respectively. There was a graded increased risk of cardiovascular mortality associated with CKD status compared with no CKD group: adjusted hazard ratio [HR] was 1.34 (95% CI: 1.07-1.68,P = 0.011) for mild CKD group, 2.17 (95% CI: 1.67-2.81,P < 0.0001) for moderate CKD group, and 2.95 (95% CI: 1.97-4.41, P < 0.0001) for severe CKD group, respectively. Risk of all-cause mortality also increased among patients with moderate or severe CKD.

CONCLUSIONS

CKD status was independently associated with progressively higher risks of major bleeding and mortality, but didn't seem to be an independent predictor of thromboembolism in AF patients.

Antithrombotic therapy in diabetes: which, when, and for how long?

Cardiovascular disease remains the main cause of mortality in individuals with diabetes mellitus (DM) and also results in significant morbidity. Premature and more aggressive atherosclerotic disease, coupled with an enhanced thrombotic environment, contributes to the high vascular risk in individuals with DM. This prothrombotic milieu is due to increased platelet activity together with impaired fibrinolysis secondary to quantitative and qualitative changes in coagulation factors. However, management strategies to reduce thrombosis risk remain largely similar in individuals with and without DM. The current review covers the latest in the field of antithrombotic management in DM. The role of primary vascular prevention is discussed together with options for secondary prevention following an ischaemic event in different clinical scenarios including coronary, cerebrovascular, and peripheral artery diseases. Antiplatelet therapy combinations as well as combination of antiplatelet and anticoagulant agents are examined in both the acute phase and long term, including management of individuals with sinus rhythm and those with atrial fibrillation. The difficulties in tailoring therapy according to the variable atherothrombotic risk in different individuals are emphasized, in addition to the varying risk within an individual secondary to DM duration, presence of complications and predisposition to bleeding events. This review provides the reader with an up-to-date guide for antithrombotic management of individuals with DM and highlights gaps in knowledge that represent areas for future research, aiming to improve clinical outcome in this high-risk population.

Many Good Reasons to Switch from Vitamin K Antagonists to Non-Vitamin K Antagonists in Patients with Non-Valvular Atrial Fibrillation

Non-vitamin K oral anticoagulants (NOACs) are the first choice for prophylaxis of cardioembolism in patients with non-valvular atrial fibrillation (AF) who are anticoagulant-naïve, as well as the preferable anticoagulation strategy in those who are on vitamin K antagonists (VKAs), but with a low time in therapeutic range (TTR). Nonetheless, there are many good reasons to consider switching from VKAs to NOACs also when TTR is >70%. From the pharmacological standpoint, anticoagulation with VKAs may remain erratic even in those patients who have high TTR values, owing to the mode of action of this drug class. Furthermore, experimental data suggest that, unlike VKAs, NOACs favorably modulate the effects of factor Xa and thrombin in the cardiovascular system through the protease-activated receptor family. Clinically, the most striking advantage provided by NOACs over VKAs, irrespective of the TTR, is the substantially lower risk of intracranial hemorrhage. NOACs have also been associated with less deterioration of renal function as compared with VKAs and may confer protection against cardiovascular events not strictly related to AF, especially the acute complications of peripheral artery disease. In this narrative review, we discuss the evidence according to which it is warranted to systematically substitute NOACs for VKAs for the prevention of AF-related stroke and systemic embolism.

Hemoperitoneum After Cardiopulmonary Resuscitation in Peritoneal Dialysis Patients: A Tale of Two Cases

End-stage renal disease (ESRD) patients are at much higher risk of cardiac arrest as compared to the general population. In the event of a cardiac arrest, cardiopulmonary resuscitation (CPR) is a lifesaving procedure. In fact, the need for CPR among hospitalized ESRD patients is almost 20 times higher than the general population. Complications of CPR include thoracic injuries such as flail chest, rib fractures, pneumothorax, and rarely intra-abdominal complications. Hemoperitoneum is a well-recognized complication among peritoneal dialysis patients but as a complication of CPR is rarely described. Inappropriate CPR technique, hepatic ischemia and venous congestion, platelet dysfunction, and the use of anti-platelet agents can increase the risk of such injury and bleeding. Hemoperitoneum in this setting can be serious with significant complications and may require transition from peritoneal dialysis (PD) to hemodialysis. We report two such PD patients who developed hemoperitoneum as a complication after CPR and their course.