Effect of oral anticoagulant therapy on mortality in end-stage renal disease patients with atrial fibrillation: a prospective study

Genovesi, Simonetta; Rebora, Paola; Gallieni, Maurizio; Stella, Andréa; Badiali, Fabio; Conte, Ferruccio; Pasquali, Sonia; Bertoli, Silvio; Ondei, Patrizia; Bonforte, Giuseppe; Pozzi, Claudio; Rossi, Emanuela; Valsecchi, Maria Grazia; Santoro, Antonio

doi:10.1007/s40620-016-0364-8

Cited by 25 publications

(23 citation statements)

References 30 publications

(9 reference statements)

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“…Other studies reported lack of association between warfarin use and mortality likely because warfarin use was parameterized as a time‐fixed exposure, potentially introducing misclassification. As Genovesi et al pointed out, it is necessary to consider the actual time of warfarin intake in the analysis for the protective effect of the drug to become evident . We accounted for the fact that warfarin users often discontinue or change their treatment at a high rate by defining warfarin use as a time‐varying variable.…”

Section: Discussionmentioning

confidence: 96%

“…Therefore, our findings may be more generalizable to older adults undergoing dialysis who may have complex oral anticoagulation treatment. While our study did not investigate the cause of death, other reports suggested that the reduction in mortality may be due to a reduction in cardiovascular death rather than stroke death …”

Section: Discussionmentioning

confidence: 96%

“…We found that warfarin use significantly reduced the risk of mortality, and this result was consistent with previous reports . We extended these previous findings to older patients with AF who were undergoing dialysis.…”

Section: Discussionmentioning

confidence: 99%

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Warfarin use and the risk of stroke, bleeding, and mortality in older adults on dialysis with incident atrial fibrillation

et al. 2019

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Section: Discussionmentioning

confidence: 96%

Section: Discussionmentioning

confidence: 96%

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Warfarin use and the risk of stroke, bleeding, and mortality in older adults on dialysis with incident atrial fibrillation

et al. 2019

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“…Recently published systematic reviews and observational studies suggest that warfarin is not beneficial in reducing stroke risk but is associated with increased bleeding risk in patients with AF undergoing dialysis [14–17], especially among older dialysis patients [18, 19]. However, there was some emerging evidence suggesting that warfarin use is associated with a reduction in mortality, even in the absence of a reduction in stroke incidence [20–24]. …”

Section: Introductionmentioning

confidence: 99%

Treatment of atrial fibrillation with warfarin among older adults with end stage renal disease

et al. 2017

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Background There is increasing evidence questioning the use of warfarin for atrial fibrillation (AF) among older adults with end stage renal disease (ESRD). We assessed the patterns and determinants of warfarin utilization among these patients in the US. Methods We assembled a cohort of older adults (age ≥65) undergoing dialysis with incident AF from July 2007 to November 2011 from the US Renal Data System (USRDS). We used descriptive statistics to characterize warfarin utilization within 30 days of AF discharge, and logistic regression to quantify patient characteristics associated with warfarin initiation. Results Among 5730 older adults undergoing dialysis with incident AF, 15.5% initiated warfarin. Among 2906 patients with high risk of bleeding, 12.7% initiated warfarin; whereas 14.9% initiated warfarin among 4824 patients with high risk of stroke. After adjustment for patient characteristics, warfarin initiation was lower among patients who were older [odds ratio (OR) = 0.74 per 10-year increase, 95% confidence interval (CI) 0.66–0.83] and those with a history of diabetes (OR = 0.75, 95% CI 0.63–0.90), myocardial infarction (OR = 0.64, 95% CI 0.50–0.80), or bleeding (OR = 0.63, 95% CI 0.50–0.80). There was no association between sex, race, or dialysis modality and warfarin initiation. Among patients who initiated warfarin, 46.8% discontinued warfarin use after a median treatment length of 8.6 months. Conclusion Despite the unclear benefit and increased bleeding risk of warfarin treatment in patients with ESRD, 1 in 8 older adults undergoing dialysis with incident AF in the US who had high risk of bleeding used warfarin. Changes to warfarin therapy due to discontinuation were common after initiation.

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“…Although a recent meta-analysis finds that VKAs do not reduce stroke rate in ESRD patients on replacement therapy, and is associated with a 30% increase in major bleeding [13], some recent studies suggest that these patients with AF when treated with VKAs have a better survival compared with patients not anticoagulated. Warfarin benefit seems to be particularly evident in patients taking VKAs without interruption, and with an INR kept in therapeutic range [33,34]. In case of DE overdose, and in case of life-threatening bleeding, haemodialysis can be used to reduce DE level, and stop bleeding [32].…”

Section: Using Direct Oral Anticoagulants In Patients With Chronic Kimentioning

confidence: 99%

Dabigatran etexilate: appropriate use in patients with chronic kidney disease and in the elderly patients

Molteni

Minno

et al. 2017

Intern Emerg Med

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Dabigatran etexilate (DE) is a direct thrombin inhibitor, which has been approved for the treatment of non-valvular atrial fibrillation (AF), and for the prevention and treatment of venous thromboembolism (VTE). Despite large randomized clinical trials and independent observational studies providing robust data concerning DE safety and efficacy, some physicians still perceive mild-to-moderate renal impairment and old age as a relative contraindication to its use. In this article, we review the available scientific evidence supporting the use of DE in these clinical situations. Patients with AF and chronic kidney disease (CKD) are per se at high risk of stroke, bleeding and mortality. Although there is evidence of clinical benefit of anticoagulation in these patients, anticoagulant therapy requires caution and demands careful clinical monitoring, regardless of the drug used. In patients with no contraindication to its use, the clinical benefit of DE versus warfarin is independent of renal function. The elderly with AF are frequently undertreated because of the perception of high bleeding risk and limited clinical benefit. However, the clinical benefit of anticoagulation is independent of patient age, and age per se should not represent a contraindication to anticoagulation. DE has been extensively studied in the elderly, both in randomized clinical trials and in observational studies: DE 150 mg BID should not be used in patients 80 years of age or older, while DE 110 mg BID is as safe as warfarin. Intracranial haemorrhages reduction by DE compared with warfarin is preserved in the elderly. Therefore, mild and moderate CKD and being elderly should not deter physicians from prescribing DE. Furthermore, the availability of a specific antidote is expected to improve the safety of the use of DE in clinical practice.

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Effect of oral anticoagulant therapy on mortality in end-stage renal disease patients with atrial fibrillation: a prospective study

Abstract: In haemodialysis patients with AF, continuously taking warfarin is associated with a reduction of the risk of total and cardiovascular mortality.

Cited by 25 publications

References 30 publications

Warfarin use and the risk of stroke, bleeding, and mortality in older adults on dialysis with incident atrial fibrillation

Warfarin use and the risk of stroke, bleeding, and mortality in older adults on dialysis with incident atrial fibrillation

Treatment of atrial fibrillation with warfarin among older adults with end stage renal disease

Dabigatran etexilate: appropriate use in patients with chronic kidney disease and in the elderly patients

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