Anticoagulation in Patients with End-Stage Renal Disease and Atrial Fibrillation: Confusion, Concerns and Consequences

Abstract

End-stage renal disease (ESRD) patients have a higher prevalence of diabetes mellitus, hypertension, congestive heart failure and advanced age, along with an increased incidence of non-valvular atrial fibrillation (AF), thereby increasing the risk for cerebrovascular accidents. Systemic anticoagulation is therefore recommended in patients with ESRD with AF to reduce the risk and complications from thromboembolism. Paradoxically, these patients are at an increased risk of bleeding due to great degree of platelet dysfunction and impaired interaction between platelet and endothelium. Currently, CHA<sub>2</sub>DS<sub>2</sub>-VASc and Hypertension, Abnormal liver/kidney function, Stroke, Bleeding, Labile INR, Elderly, Drugs or alcohol (HAS-BLED) are the recommended models for stroke risk stratification and bleeding risk assessment in patients with AF. There is conflicting data regarding benefits and risks of medications such as antiplatelet agents, warfarin and direct oral anticoagulants in ESRD patients with AF. Moreover, there is no randomized controlled trial data to guide the clinical decision making. Hence, a multi-disciplinary approach with annual re-evaluation of treatment goals and risk-benefit assessment has been recommended. In this article, we review the current recommendations with risks and benefits of anticoagulation in patients with ESRD with AF.

Antithrombotic therapy in diabetes: which, when, and for how long?

“…For example, advanced renal disease may alter both thrombosis and bleeding risk and may even limit the use of some antithrombotic therapies. 33 The increased weight in DM individuals may also affect the response to antithrombotic agents, reviewed elsewhere. 160 A key difficulty remains the lack of biomarker(s) that accurately predicts thrombotic/bleeding risk and response to therapy.…”

“… 31 , 32 The exact mechanisms for the increase in both thrombosis and bleeding risk in some diabetes patients are not fully understood, although renal complications may have a role. 33 Also, chronic activation of platelet and coagulation proteins may ‘exhaust’ the system in some DM patients, thus increasing bleeding risk. 34 …”

<p>Hemoperitoneum After Cardiopulmonary Resuscitation in Peritoneal Dialysis Patients: A Tale of Two Cases</p>

“… 9 Moreover, ESRD patients are already at an increased risk of bleeding due to platelet dysfunction. 13 Both reported PD patients were on anti-platelet agents which likely enhanced their susceptibility to bleeding ( Table 1 ).…”

Diabetes und kardiovaskuläre Ereignisse

“…Dies wurde bei der antithrombotischen Therapie im Zusammenhang mit einem akuten Koronarsyndrom festgestellt 8 , scheint jedoch nicht für die primär- oder sekundärpräventive Langezeittherapie zu gelten 9 , 10 . Der genaue Mechanismus für den gleichzeitigen Anstieg des Thrombose- und des Blutungsrisikos ist noch nicht genau verstanden, eine Abhängigkeit von der Diabetesdauer und eine Beteiligung der diabetischen Nephropathie kann nicht ausgeschlossen werden 11 .…”