The nephrologist’s anticoagulation treatment patterns/regimens in chronic hemodialysis patients with atrial fibrillation

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

doi:10.1007/s40620-013-0030-3

Cited by 14 publications

(22 citation statements)

References 27 publications

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“…We found that several predictors of stroke risk including advanced age, history of diabetes and myocardial infarction were inversely associated with warfarin initiation, which differed from Genovesi et al's observation that these factors were not significantly associated with warfarin prescription [37]. The magnitude of these factors reported by Genovesi et al were in the same direction as ours (i.e.…”

Section: Discussioncontrasting

confidence: 95%

“…We found that bleeding history was inversely associated with warfarin initiation, but bleeding risk score and stroke risk score were not associated after adjustment for other patient characteristics. Genovesi et al found that previous bleedings and hemorrhagic risk score was inversely related to warfarin use, but stroke risk score was not associated with warfarin use [37]. Such discrepancy might be due to differences in the study population and the definition of warfarin use: Genovesi et al studied a mixed population of new and chronic warfarin among chronic HD patients with AF in Italy [37], whereas we studied new users among older adults undergoing HD or PD with incident AF in the US.…”

Section: Discussionmentioning

confidence: 99%

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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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Section: Discussioncontrasting

confidence: 95%

Section: Discussionmentioning

confidence: 99%

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

et al. 2017

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“…Continued warfarin therapy in a form of "prescriptive inertia" was followed by the influence of the dominant practice guideline [17]. Gevovesi study reported that 44.5% of HD patients and AF received oral anticoagulation (OAT) [18].…”

Section: Introductionmentioning

confidence: 99%

Warfarin use and the risks of stroke and bleeding in hemodialysis patients with atrial fibrillation: A systematic review and a meta-analysis

Wang

et al. 2015

Nutrition, Metabolism and Cardiovascular Diseases

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“…The CHADS 2 score is not associated with warfarin prescription. This turns into a low prevalence of warfarin prescription (less than 50% of the patients) [27]. In this specific setting characterized by a very high mortality, anticoagulation seems to be associated with a better survival; furthermore, patients with the highest time of International Normalized Ratio (INR) in therapeutic range had the lowest bleeding rate [28].…”

Section: Estimation Of Renal Functionmentioning

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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The nephrologist’s anticoagulation treatment patterns/regimens in chronic hemodialysis patients with atrial fibrillation

Cited by 14 publications

References 27 publications

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

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

Warfarin use and the risks of stroke and bleeding in hemodialysis patients with atrial fibrillation: A systematic review and a meta-analysis

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

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