Relationships between Anticoagulation, Risk Scores and Adverse Outcomes in Dialysis Patients with Atrial Fibrillation

Wang, Tom Kai Ming; Sathananthan, Janarthanan; Marshall, Mark R.; Kerr, Andrew; Hood, Chris

doi:10.1016/j.hlc.2015.08.012

Cited by 45 publications

(64 citation statements)

References 28 publications

(78 reference statements)

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“…2). Point estimates from 7 previous studies suggest lower mortality [17,[20][21][22][23][41][42][43], and 5 of them demonstrated statistically significant reductions in death rate among VKA users [17,20,21,23,42] . Consistent with the results, our study showed that the benefits of warfarin therapy might not be offset by an increased risk of fatal side effects in HD patients.…”

Section: Discussionmentioning

confidence: 94%

Patients' Characteristics Affect the Survival Benefit of Warfarin Treatment for Hemodialysis Patients with Atrial Fibrillation. A Historical Cohort Study

Brancaccio

Neri²,

Bellocchio³

et al. 2016

Am J Nephrol

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Background: Stroke prevention in dialysis-dependent patients with atrial fibrillation (AF) is an unresolved clinical dilemma. Indeed, no randomized controlled trial evaluating the efficacy and safety of oral anticoagulants in this population, has been conducted so far. Observational research on the use of warfarin in patients on dialysis has shown conflicting results. This uncertainty is mirrored by the wide variations in warfarin prescription patterns across centers. We sought to evaluate the association between the use of vitamin K antagonists (VKAs) and mortality among hemodialysis patient with AF and to assess potential factors affecting the risk-benefit profile of warfarin in this population. Methods: A total of 91,987 patients registered in the European Clinical Dialysis Database® system from January 2004 to January 2015. Of which, 9,238 patients were identified with a diagnosis of AF. After excluding ineligible patients, a 1:1 propensity score matched cohort of 1,324 warfarin users and non-users were assembled. Results: VKA use was associated with both increased 90-day survival (hazard ratio, HR 0.47, p < 0.01) and 6-year survival (HR 0.76, p < 0.01); however, a trend indicated a stronger early benefit (p for time-interaction <0.01). Moderation analysis showed that patients' age and clinical history of stroke strongly influenced warfarin-related benefits on survival. Conclusion: VKA may provide an early survival benefit; however, this is partially offset later during the follow-up. In addition, heterogeneous risk-benefit profiles were observed among subgroups of dialysis-dependent patients with AF, further emphasizing the complexities of tailoring stroke prevention strategies in this population.

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Section: Discussionmentioning

confidence: 94%

Patients' Characteristics Affect the Survival Benefit of Warfarin Treatment for Hemodialysis Patients with Atrial Fibrillation. A Historical Cohort Study

Brancaccio

Neri²,

Bellocchio³

et al. 2016

Am J Nephrol

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“…In the adjusted HR analysis (7 studies,23–26 31 33 34 n=8477) and unadjusted analysis (8 studies,24 25 28 31–35 n=15 797), there were no difference in the all-cause mortality between warfarin users or non-warfarin users. The adjusted HR and unadjusted RR were 0.99 (95% CI 0.89 to 1.10; p=0.825; figure 2A) and 1.00 (95% CI 0.96 to 1.04; p=0.847; figure 2B), respectively.…”

Section: Resultsmentioning

confidence: 99%

“…Not surprisingly, warfarin therapy was associated with an increased risk of major bleeding for adjusted (7 studies,24 25 27 29 31 33 34 n=23 178) and unadjusted (7 studies,24 25 27–29 31 33 n=31 723) analyses. The adjusted HR and unadjusted IRR were 1.35 (95% CI 1.11 to 1.64; p=0.003; figure 4A) and 1.22 (95% CI 1.07 to 1.40; p=0.003; figure 4B), respectively.…”

Section: Resultsmentioning

confidence: 99%

Efficacy and safety of warfarin in dialysis patients with atrial fibrillation: a systematic review and meta-analysis

et al. 2016

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ObjectiveTo 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.MethodsWe 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 measureAll-cause mortality, total stroke/thromboembolism and bleeding complications.Results14 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).ConclusionsAmong 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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“…The mean age of patients (warfarin user) included in the meta‐analysis was 69.85 ± 9.43 years with 37.14% of female. Bleeding was assessed using the HAS‐BLED score in the majority of the studies . Confirmation of exposure with warfarin was confirmed through medical records or prescription claims in most of the included studies.…”

Section: Resultsmentioning

confidence: 99%

Warfarin use increases bleeding risk in hemodialysis patients with atrial fibrillation: A meta‐analysis of cohort studies

Hussain

Siddiqui

Baxi

et al. 2019

J of Gastro and Hepatol

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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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Relationships between Anticoagulation, Risk Scores and Adverse Outcomes in Dialysis Patients with Atrial Fibrillation

Cited by 45 publications

References 28 publications

Patients' Characteristics Affect the Survival Benefit of Warfarin Treatment for Hemodialysis Patients with Atrial Fibrillation. A Historical Cohort Study

Patients' Characteristics Affect the Survival Benefit of Warfarin Treatment for Hemodialysis Patients with Atrial Fibrillation. A Historical Cohort Study

Efficacy and safety of warfarin in dialysis patients with atrial fibrillation: a systematic review and meta-analysis

Warfarin use increases bleeding risk in hemodialysis patients with atrial fibrillation: A meta‐analysis of cohort studies

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