Reduction of intracerebral hemorrhage in hemodialysis patients after reducing aspirin use: A quality-assurance observational study

Abstract

There is so far no international consensus concerning the prescription of antithrombotic agents in hemodialysis patients. It is not clear yet why they cause more bleeding in some patients and are beneficial in others. We therefore tried to find out what triggers bleeding in this population. This is an observational before-and-after study that included all patients undergoing hemodialysis in our center between 2005 and 2015. We divided the study into two phases: phase one (125 patients) where aspirin was used without restrictions and phase two (110 patients) where aspirin was avoided in severe hypertension and primary prevention. We aimed to assess the differential occurrence of intracerebral hemorrhage between the two phases and the cardiovascular mortality of patients whether on aspirin or not. Bleeding events occurred in 12.8% of patients in phase one and 13.6% in phase two (p = 0.85). Seven out of 125 patients (6%) in phase one experienced intracerebral hemorrhage and none in phase two. Intracerebral hemorrhage was significantly increased in those with the combination of aspirin and severe hypertension (p = 0.003). Aspirin and acenocoumadin were significantly associated with total bleeding (OR = 3.81 and 4.85 with p = 0.005 and 0.001 respectively). Cardiovascular mortality did not differ between phase one and two whether patients were on aspirin or not (p = 0.45 and 0.31 respectively). Minimizing aspirin use in hemodialysis patients with severe hypertension reduced intracerebral bleeding without a significant difference in cardiovascular mortality.

Clinical Profile and Outcome of Intracranial Bleeding in Patients Undergoing Hemodialysis at a Tertiary Hospital

“…If intracerebral bleeding does occur in a dialysis patient, systemic heparinization can increase the hematoma size (30) and worsen the outcome. The use of aspirin was associated with increased intracerebral bleeding in a study and did not confer significant benefit to cardiovascular outcome (31). Our current study showed no significant difference in the average heparin dose and antiplatelet use between the case and control groups.…”

Correlation between a Bedridden Status and the Long-term Outcome in Hemodialysis Patients after Intracerebral Hemorrhaging

“…The involvement of antiplatelet drugs in causing cerebral hemorrhaging in dialysis patients is controversial. Some studies have reported that antiplatelet drugs do not affect the patient prognosis (13,14), while others have reported that they increase the risk of a poor prognosis among hemodialysis patients with cerebral hemorrhaging (8)(9)(10)(11)(12)(13)(14)(15). Antiplatelet drugs are thought to increase the volume of hematomas, as they are hemorrhagic in nature, and a growing hematoma can irreversibly damage the brain.…”

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

“…Bleeding risk (ICH) was more pronounced with aspirin use among patients with severe hypertension (pre-dialysis systolic blood pressure >160 mm Hg). 46 Due to conflicting data regarding risks and benefits of antiplatelet medication use among ESRD patients with AF, there is no consensus or guideline regarding their routine use. Results from a randomized controlled trial to assess aspirin use in ESRD patients to reduce the risk of thrombotic events are awaiting.…”

“…Risk of bleeding was slightly more pronounced with combination of warfarin and aspirin (HR, 1.71; 95% CI, 0.98 to 2.99; P =0.06). Bleeding risk (ICH) was more pronounced with aspirin use among patients with severe hypertension (pre-dialysis systolic blood pressure >160 mm Hg) [ 46 ]. Due to conflicting data regarding risks and benefits of antiplatelet medication use among ESRD patients with AF, there is no consensus or guideline regarding their routine use.…”