Oral Anticoagulation for Patients With Atrial Fibrillation on Long-Term Dialysis

Kuno, Toshiki; Takagi, Hisato; Ando, Tomo; Sugiyama, Takehiro; Miyashita, Satoshi; Valentin, Nelson; Shimada, Yuichi J.; Kodaira, Masaki; Numasawa, Yohei; Briasoulis, Αlexandros; Burger, Alfred; Bangalore, Sripal

doi:10.1016/j.jacc.2019.10.059

Cited by 134 publications

(107 citation statements)

References 40 publications

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“…The study was terminated prematurely and showed similar rates of bleeding with apixaban and warfarin [33]. We are waiting for the results of the AXADIA trial, but at present no studies are available to support the hypothesis that DOACs represent an advantage for thromboembolic prevention over warfarin in ESRD patients with AF [34]. LAA occlusion therefore is an option to be taken into consideration for subjects with advanced CKD and particularly high bleeding risk.…”

Section: Discussionmentioning

confidence: 99%

Outcomes on safety and efficacy of left atrial appendage occlusion in end stage renal disease patients undergoing dialysis

et al. 2020

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Background In patients with end stage renal disease and atrial fibrillation (AF), undergoing chronic dialysis, direct oral agents are contraindicated and warfarin does not fully prevent embolic events while increasing the bleeding risk. The high hemorrhagic risk represents the main problem in this population. Aim of the study was to estimate the safety and efficacy for thromboembolic prevention of left atrial appendage (LAA) occlusion in a cohort of dialysis patients with AF and high hemorrhagic risk. Methods Ninety-two dialysis patients with AF who underwent LAA occlusion were recruited. For comparative purposes, two cohorts of dialysis patients with AF, one taking warfarin (oral anticoagulant therapy, OAT cohort, n = 114) and the other not taking any OAT (no-therapy cohort, n = 148) were included in the study. Primary endpoints were (1) incidence of peri-procedural complications, (2) incidence of 2-year thromboembolic and hemorrhagic events, (3) mortality at 2 years. In order to evaluate the effect of the LAA occlusion on the endpoints with respect to the OAT and No-therapy cohorts, a multivariable Cox regression model was applied adjusted for possible confounding factors. Results The device was successfully implanted in 100% of cases. Two major peri-procedural complications were reported. No thromboembolic events occurred at 2-year follow-up. The adjusted multivariable Cox regression model showed no difference in bleeding risk in the OAT compared to the LAA occlusion cohort in the first 3 months of follow-up [HR 1.65 (95% CI 0.43-6.33)], when most of patients were taking two antiplatelet drugs. In the following 21 months the bleeding incidence became higher in OAT patients [HR 6.48 (95% CI 1.32-31.72)]. Overall mortality was greater in both the OAT [HR 2.76 (95% CI 1.31-5.86)] and No-Therapy [HR 3.09 (95% CI 1.59-5.98)] cohorts compared to LAA occlusion patients. Conclusions The study could open the way to a non-pharmacological option for thromboembolic protection in dialysis patients with AF and high bleeding risk.

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Section: Discussionmentioning

confidence: 99%

Outcomes on safety and efficacy of left atrial appendage occlusion in end stage renal disease patients undergoing dialysis

et al. 2020

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“…Disagreements between the reviewers regarding the extracted data were resolved through discussion with a third reviewer (T.K.). 18 The following data were extracted: first author name, date of publication, type of study (retrospective study, case report, case series, or prospective study), country, cohort size, and characteristics of ocular symptoms in patients with COVID-19 including age, sex, and ocular findings. Ocular findings were assessed based on prodromal ocular symptoms, clinical ocular symptoms, ocular therapeutic management, and ocular RT-PCR results using conjunctival and tear samples.…”

Section: Data Extractionmentioning

confidence: 99%

Clinical and Prodromal Ocular Symptoms in Coronavirus Disease: A Systematic Review and Meta-Analysis

Inomata

Kitazawa

Kuno

et al. 2020

Invest. Ophthalmol. Vis. Sci.

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This systematic review aimed to determine currently reported clinical and prodromal ocular symptoms in patients with coronavirus disease 2019 (COVID-19). METHODS. An online article search was performed in PubMed and EMBASE. Altogether 15 studies (retrospective, prospective, or case studies) involving 1533 patients with COVID-19, reporting on ocular symptoms, and with outcome data available were identified. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines were followed. Study-specific estimates (incidence rates of ocular symptoms in patients with COVID-19) of cases were combined using one-group meta-analysis in a random-effects model. RESULTS. Of all included studies, 11.2% (95% confidence interval, 5.5-16.9; 78/1526 cases) reported ocular symptoms. The most common ocular finding was conjunctivitis. Prodromal ocular symptoms occurred in 12.5% (13/104 cases) of patients with COVID-19. Positive real-time polymerase chain reaction results were obtained for 16.7% (10/60 cases) of conjunctival samples and 0% (0/17 cases) of tear samples. Twelve ocular conjunctival swab samples tested positive for SARS-CoV-2. Ten cases were from subjects showing ocular symptoms (16.7%, 10/60 cases), and the remaining two cases were from subjects without ocular manifestation (1.8%, 2/113 cases). Limitations included the short study period, small sample size, findings were limited to the Asian population, only seven articles included ophthalmologic examination details, and there is currently no consensus on COVID-19 management. CONCLUSIONS. Ocular symptoms may occur in the presymptomatic phase as a prodromal symptom (12.5%, 13/104 cases), suggesting the possibility of viral transmission from the conjunctiva.

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“…57 In a meta-analysis involving five studies and 43,850 advanced CKD and ESRD patients, apixaban was associated with lower risk of bleeding but similar risk of thromboembolic event 60 Use of other DOACs such as dabigatran and rivaroxaban is also associated with significant risk of bleeding as compared to apixaban. 59 Randomized controlled trials involving apixaban and warfarin in ESRD/AF are underway (NCT02933697 and NCT02942407) which hopefully will shed more light on appropriate dosage, safety and efficacy of these agents in ESRD. As noted, most of available data pertains to HD patients.…”

Section: Use Of Doacs In Esrd For Cva/tia Preventionmentioning

confidence: 99%

“…57 Table 2 summarizes the major studies investigating role of antiplatelet agent as aspirin, vitamin K antagonist as warfarin and DOAC as apixaban in ESRD patients with AF. 4,5,10,43,44,[57][58][59][61][62][63][64][65]…”

Section: Table 2 Continuedmentioning

confidence: 99%

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

Goel¹,

Jain²,

Haddad³

et al. 2020

J Stroke

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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.

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Oral Anticoagulation for Patients With Atrial Fibrillation on Long-Term Dialysis

Cited by 134 publications

References 40 publications

Outcomes on safety and efficacy of left atrial appendage occlusion in end stage renal disease patients undergoing dialysis

Outcomes on safety and efficacy of left atrial appendage occlusion in end stage renal disease patients undergoing dialysis

Clinical and Prodromal Ocular Symptoms in Coronavirus Disease: A Systematic Review and Meta-Analysis

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

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