Preventing arteriovenous shunt failure in hemodialysis patients: a population‐based cohort study

Abstract

Uncertainty remains about antiplatelets for vascular access patency in hemodialysis patients. 95 971 people under hemodialysis were followed in a claims database in Taiwan. Aspirin reduced vascular access failure rate and did not increase major bleeding rate. Clopidogrel, Aggrenox, and warfarin might increase major bleeding rate. Summary BackgroundDialysis adequacy is a major determinant of survival for patients with end‐stage renal disease. Good vascular access is essential to achieve adequate dialysis. ObjectivesThis study evaluated the impacts of different drugs on the vascular access failure rate of an arteriovenous fistula or an arteriovenous graft and the rate of major bleeding in hemodialysis patients. Patients and methodsWe studied patients with end‐stage renal disease registered in the Taiwan National Health Insurance program from 1 January 1997 to 31 December 2012. A total of 95 971 patients were enrolled in our study. Vascular access dysfunction was defined as the need for thrombectomy or percutaneous angioplasty. Major bleeding was defined as emergency department visits or hospitalization with a primary diagnosis of gastrointestinal bleeding or intracerebral hemorrhage. The adjusted odds ratios between person‐quarters with or without antiplatelet or oral anticoagulant use were calculated using a generalized estimating equation. ResultsThe odds ratio of vascular access failure was 0.21 (0.11–0.39) for aspirin, 0.76 (0.74–0.79) for clopidogrel, 0.67 (0.59–0.77) for dipyridamole, 0.67 (0.53–0.86) for Aggrenox and 0.96 (0.90–1.03) for warfarin. The highest odds ratio for intracerebral hemorrhage was 5.33 (1.25–22.72) in younger patients using Aggrenox. The highest odds ratio for gastrointestinal bleeding was 1.34 (1.10–1.64) for clopidogrel. ConclusionAntiplatelet agents, but not warfarin, might reduce the vascular access thrombosis rate. The gastrointestinal bleeding rate was increased in the group using clopidogrel. Aggrenox should be used with caution in young individuals because it might increase the rate of intracerebral hemorrhage.

Outcomes after Percutaneous Angioplasty of Arteriovenous Fistulas and Grafts in African American Patients

“…A retrospective evaluation of over 90,000 ESRD patients in the Taiwan National Health Insurance Program were studied to estimate the efficacy of thrombosis prevention and risk of bleeding with different antiplatelet agents and oral anticoagulants. Anti-platelet agents, but not warfarin, reduced the risk of vascular access thrombosis rate, but there was an increased risk of bleeding with clopidogrel and aspirin-dipyridamole [28]. An analysis of 24,847 hemodialysis patients who had vascular access placement from the Society for Vascular Surgery Vascular Quality Initiative showed that primary patency of AVG but not AVF was improved in patients receiving antiplatelet therapy.…”

Concurrent use of statins decreases major bleeding and intracerebral hemorrhage in non-valvular atrial fibrillation patients taking direct oral anticoagulants—A nationwide cohort study

“…One person-quarter (PQ) was used as an analytical unit. We used PQs because medications for chronic illnesses were refilled with a maximum duration of 3 months per the Taiwan NHI reimbursement policy ( 16 , 18 ). Medications and covariates were assessed for each PQ, and PQs exposed to DOACs with or without statins were identified.…”

Frequent vascular access thrombosis in a patient with end stage kidney disease on hemodialysis

“…From the DOPPS observational study, use of warfarin was associated with worse primary graft patency (RR 1.33; P = 0.037) 19 . A retrospective cohort study from Taiwan showed no benefit from warfarin use at reducing need for thrombectomy or percutaneous angioplasty, but use of warfarin significantly increased risk of ICH 20 . A 2002 RCT of 107 ESKD patients with PTFE grafts in Ontario, Canada, randomized patients to low intensity warfarin (INR goal 1.5–1.9) or placebo and showed no significant difference in graft survival but did show significantly increased major bleeding in the treatment arm 21 .…”

“…19 A retrospective cohort study from Taiwan showed no benefit from warfarin use at reducing need for thrombectomy or percutaneous angioplasty, but use of warfarin significantly increased risk of ICH. 20 A 2002 RCT of 107 ESKD patients with PTFE grafts in Ontario, Canada, randomized patients to low intensity warfarin (INR goal 1.5-1.9) or placebo and showed no significant difference in graft survival but did show significantly increased major bleeding in the treatment arm. 21 The effect of direct oral anticoagulants on VAT is not known currently and is an area of ongoing research (NCT04489849).…”