Association Between Use of Warfarin for Atrial Fibrillation and Outcomes Among Patients With End-Stage Renal Disease

Abstract

IMPORTANCE Several studies have examined the role of warfarin in preventing strokes in patients with atrial fibrillation and end-stage renal disease; however, the results remain inconclusive. OBJECTIVE To assess recently published studies to examine the outcomes of the use of warfarin among patients with atrial fibrillation and end-stage renal disease. DATA SOURCES A literature search was performed using the terms warfarin and atrial fibrillation and end-stage renal disease and warfarin and atrial fibrillation and dialysis in the MEDLINE, Embase,

Should Oral Anticoagulation Be Used in ESKD Patients on Hemodialysis with Atrial Fibrillation?: CON

“…For example, a recent meta-analysis of 15 observational studies including 47,480 ESKD patients with AF showed that as compared to no anticoagulation, warfarin use in ESKD did not improve rates of mortality (HR, 0.95; 95% CI, 0.83-1.09) or ischemic stroke (HR, 0.96; 95% CI, 0.82-1.13). 2 This study is not alone; a previous metaanalysis of 20 observational studies involving 31,321 patients with ESKD and AF also showed no benefit to anticoagulation in terms of all-cause (relative risk 0.97, 95% CI 0.90 to 1.04) and cardiovascular mortality (relative risk 0.99, 95% CI 0.86 to 1.15). Indeed, the anticoagulated patients actually had a higher risk of stroke.…”

“…9 Another metaanalysis also demonstrated higher risk of hemorrhagic stroke among hemodialysis patients receiving warfarin compared to those not on anticoagulation (HR, 1.49; 95% CI, 1.03-1.94). 2 A study of patients from a Danish registry also reported an increased risk of bleeding in ESKD patients treated with warfarin compared to those not treated with warfarin. 7 In addition to increased risk of bleeding, another possible adverse effect related to warfarin use in dialysis patients is an increased risk of vascular calcification and calciphylaxis.…”

Review of Medical Therapies for the Management of Pulmonary Embolism

“…Cancer patients have a five to seven-fold increased risk for VTE within the first year of diagnosis [ 89 ]. Additionally, VTE is considered an independent predictor of mortality in these patients [ 90 , 91 ]. The pathophysiological and epidemiological association between PE and cancer is well established.…”

Clinical Evidence for the Choice of the Direct Oral Anticoagulant in Patients with Atrial Fibrillation According to Creatinine Clearance

“…Available evidence showed that warfarin increased the rate of bleeding events without any impact on stroke prevention or death [ 31 ]. A recent meta-analysis gathered all the literature in the field and confirmed warfarin inefficacy for ischemic stroke prevention among patients on dialysis; hemorrhagic strokes were significantly higher in those receiving treatment, but mortality was comparable between groups [ 32 ]. Factors that can explain these observations include the routine administration of heparin during dialysis and the interference of uremic state with the metabolisms of warfarin, making it difficult to maintain the international normalized ratio in the therapeutic range [ 33 , 34 , 35 , 36 ].…”