Impact of restarting warfarin therapy in renal disease anticoagulated patients with gastrointestinal hemorrhage

Abstract

Background: Atrial fibrillation (AF) is emerging as a major health problem. The prevalence is as high as 32% in patients with renal disease. Gastrointestinal bleeding (GIB) is a frequent complication. Objective: To investigate the hazards of resumption or discontinuation of anticoagulation in renal disease patients after an episode of GIB. Design, settings, participants and measurements: This is a multicenter retrospective cohort of patients with AF on warfarin that developed an episode of GIB. Chronic kidney disease (CKD) was defined by eGFR 60 mL/ min and end stage renal disease (ESRD) was defined by being on hemodialysis for 43 months. Outcomes were 90-day recurrent gastrointestinal bleeding (GIB), mortality, and stroke/transient ischemic attack (TIA). Results: Out of 11,513 AF patients, index GIB occurred in 96 ESRD and 159 CKD patients. Outcomes of CKD patients did not differ when compared with patients with normal kidney function. CKD patients who resumed warfarin had decreased stroke/TIA rates (p50.0001). There were no significant differences between CKD patients who resumed warfarin versus that did not resume warfarin (p40.05). ESRD patients also did not have significant differences in outcomes when compared to patients with normal kidney function restarted on warfarin. However, there was an increase in recurrent GIB and decrease in mortality as well as stroke/TIA when patients with ESRD that restarted warfarin were compared with ESRD patients who did not restart warfarin. Conclusion: Study suggests resuming warfarin after an episode of GIB in CKD patients but recommends considering the increased risk of recurrent GIB in ESRD patients.

Response to Letter Regarding Article, “Warfarin Use and the Risk for Stroke and Bleeding in Patients With Atrial Fibrillation Undergoing Dialysis”

“…1,2 Contrary to only gastrointestinal bleeding in the study by Khalid et al, 1 the "bleeding" definition in our study included intracerebral bleeding, gastrointestinal bleeding, intraocular bleeding, hematuria, and unspecified location of bleeding, which could be a possible reason for the difference in bleeding risk between the 2 studies.…”

“…Qureshi and colleagues also mentioned that they observed a 78% reduction in the risk of mortality in hemodialysis patients with AF who were on warfarin compared with those not on warfarin and mentioned that mortality risk assessment could be important when considering risk-benefit assessment on warfarin use in AF patients undergoing dialysis. 1 Chan and colleagues 4 also conducted a similar study and found that warfarin use was associated with a 27% higher risk of mortality in hemodialysis patients. In our AF cohort, we had access to information on patients' mortality (all-cause mortality).…”

“…1,2 Similar to Khalid et al, 1 Winkelmayer and colleagues 3 studied the association between warfarin use and the risk of gastrointestinal bleeding in hemodialysis patients with AF and found no association. Qureshi and colleagues also mentioned that they observed a 78% reduction in the risk of mortality in hemodialysis patients with AF who were on warfarin compared with those not on warfarin and mentioned that mortality risk assessment could be important when considering risk-benefit assessment on warfarin use in AF patients undergoing dialysis.…”

Letter by Qureshi et al Regarding Article, “Warfarin Use and the Risk for Stroke and Bleeding in Patients With Atrial Fibrillation Undergoing Dialysis”

“…In a US cohort, we reported a 72% increase in risk of gastrointestinal bleeding in hemodialysis patients on warfarin compared with hemodialysis patients not on warfarin. 2 However, very rarely did this bleeding lead to a fatality. We believe that the reason for the lower incidence of bleeding compared with that in our study is that Shah et al analyzed peritoneal dialysis and hemodialysis patient collectively.…”

“…Moreover, in our analysis, we noticed a 78% reduction in mortality risk among dialysis patients on warfarin compared with dialysis patients not on warfarin. 2 This is an important consideration because mortality is an important outcome to consider in these patients when risk-benefit decisions are being made. This beneficial effect of warfarin to prevent cardiovascular mortality is almost similar to that of aspirin, as noted in many previous trials.…”