Benefit Of Anticoagulants In Atrial Fibrillation Diminished In End-Stage Kidney Disease

In patients with end-stage renal disease (ESRD) and atrial fibrillation (AF), anticoagulants don't cut the risk of stroke and instead appear to increase the risk for serious bleeding, a new report suggests.

Using Medicare claims data from 2007 to 2013, researchers studied more than 8,000 patients with AF and ESRD, including 3,043 (36.2%) who were treated with oral anticoagulants at some time during that period. Propensity scores were used to match 1,519 patients on oral antocoagulants with 3,018 not on OAC.

Ninety percent of anticoagulated patients in the study were receiving warfarin, the researchers note in The Journal of the American College of Cardiology.

Treatment with oral anticoagulants was not associated with hospitalization for stroke (hazard ratio [HR]: 1.00) or death (HR: 1.02). It was, however, associated with an increased risk of hospitalization for bleeding (HR:1.26; P = 0.002) and intracranial hemorrhage (HR: 1.30; P = 0.009).

"At present, it is not clear what (if any) is the best treatment option for preventing stroke in patients with atrial fibrillation and end-stage renal disease," study leader Dr. Jonathan Piccini Sr. of Duke University Medical Center in Durham, North Carolina, told Reuters Health by email. "It may be that a non-pharmacologic approach, like left-atrial-appendage occlusion, may be safer and more effective than oral anticoagulation in these patients who are at high risk for both bleeding and stroke events. However, we need a clinical trial to test this hypothesis."

In an editorial, Dr. Jonas Bjerring Olesen and Dr. Anders Nissen Bonde of Herlev and Gentofte University Hospital in Hellerup, Denmark, note that the combined results of two studies comparing apixaban and warfarin in patients with AF and ESRD—one still underway (AXADIA-AFNET 8) and one stopped early (RENAL-AF)—"will hopefully settle the role of apixaban as an anticoagulant among patients with hemodialysis."

But "the burning question," they continue, "is whether patients on dialysis with atrial fibrillation should receive anticoagulation at all. Only the (Danish Warfarin dialysis study, or DANWARD) which aims to include 718 dialysis patients, will compare anticoagulation against no anticoagulation, but several years will pass before results from this study will be presented."

In the meantime, should oral anticoagulants be stopped in patients with ESRD? Dr. Piccini advises, "Patients with AF and ESRD and their physicians need to rely on shared decision making to consider each patient's circumstances and each patient's preferences when selecting or committing to drug therapy for stroke prevention."

—Nancy Lapid

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