Warfarin use and incidence of stroke in Japanese hemodialysis patients with atrial fibrillation

Abstract

Atrial fibrillation (AF) is one of the major risk factor for ischemic stroke, and oral anticoagulation is generally indicated for prevention of stroke. However, the utility of oral anticoagulation for AF in dialysis patients remains controversial. In this single-center, retrospective, observational study, data from 1120 patients on maintenance hemodialysis were analyzed. Baseline medical data were collected from dialysis records including age, gender, the cause of end-stage renal disease, dialysis vintage, and comorbidities. We evaluated outcomes including stroke, major hemorrhage, and death. A total of 106 (11.4 %) patients had AF. After exclusion criteria were applied, 84 patients had analyzable data. Warfarin was prescribed in 30 (35.7 %) of these patients. The remaining 54 patients were classified as the non-warfarin group. CHADS2 score was not significantly different between the warfarin and non-warfarin group. During the mean 47 months of follow up, 7 strokes occurred. However, warfarin use was not associated with the risk for stroke [hazard ratio (HR) 1.07; 95 % confidence interval (CI) 0.20-5.74]. Kaplan-Meier analysis showed no statistically significant difference in the overall survival, stroke-free survival or bleeding-free survival between the warfarin and non-warfarin group. AF is common in Japanese dialysis patients. Despite a certain prevalence of oral anticoagulation, the present study demonstrated neither beneficial nor detrimental effects. A large randomized controlled trial should be considered.

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

“…In the first pass, 2139 articles (after removal of duplicates, n = 218) were screened against the inclusion and exclusion criteria based on the screening of the title and abstract. Finally, only 15 articles 2,4,7,8,11,12,[29][30][31][32][33][34][35][36][37] were qualified for inclusion in the meta-analysis after a full-text screening of the articles in the second pass. We found two retrospective cohort studies by Tan et al 3,33 using US Renal Data System.…”

“…All the included studies were a cohort in nature, of which 12 were retrospective cohort 2,4,7,8,[29][30][31][32][33][35][36][37] and three were prospective cohort studies. 11,12,34 This meta-analysis compromised of 53 581 patients of whom 17 469 patients were on warfarin.…”

Warfarin use and stroke, bleeding and mortality risk in patients with end stage renal disease and atrial fibrillation: a systematic review and meta-analysis

“…Due to the observational nature of cohort studies, all 20 included studies had at least an overall rating of moderate risk of bias: 5 studies were rated as moderate [ 22 , 25 – 28 ]; 7 studies were rated as serious [ 13 , 14 , 20 , 23 , 24 , 30 , 31 ]; 8 studies were rated as having a critical risk of bias [ 14 – 16 , 21 , 29 , 32 – 35 ] (Table 2 , Appendix Table 4).…”

“…Compared to previously published systematic reviews [ 7 – 10 ], our review included several studies recently published [ 15 , 16 , 35 ] and expanded the study population to include PD [ 21 ] and stage 5 CKD [ 25 ], which were not included in these reviews [ 7 – 9 , 36 ]. Our pooled estimate of ischemic stroke and bleeding outcomes were consistent in direction and magnitude with those reported by Li et al, Liu et al and Dahal et al [ 7 , 8 , 10 ].…”

Atrial fibrillation and chronic kidney disease: A review of options for therapeutic anticoagulation to reduce thromboembolism risk

“…Another study demonstrated greater than 2‐fold increased risk of stroke in patients 75 or older . Several other small studies between 2011 and 2016 demonstrated no benefit in terms of mortality or stroke or thromboembolism prevention …”