Warfarin use in hemodialysis patients with atrial fibrillation: decisions based on uncertainty

Thomson, Benjamin; Clase, Catherine M.; Blake, Peter G.; Moist, Louise

doi:10.1186/1471-2369-14-174

Cited by 18 publications

(22 citation statements)

References 30 publications

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“…Therefore, whether the benefits of oral anticoagulation extend to patients undergoing hemodialysis is unclear,(23-25) as they have a substantially higher risk of stroke compared to the general population, but also a higher risk of bleeding(13, 23-26). This clinical equipoise was reflected in a survey of Canadian nephrologists, where 72% were unsure about whether to initiate warfarin in hemodialysis patients with AF(27), and in the particularly low rate of warfarin use in hemodialysis patients with prevalent AF where one quarter were on warfarin. (28) In our study of a large cohort of patients on hemodialysis with newly-diagnosed AF, we found that only 15% of patients initiated warfarin use within 30 days of the index AF event; only roughly 11% of patients without an initially filled warfarin prescription initiated treatment between 30 days and one year.…”

Section: Discussionmentioning

confidence: 99%

Outcomes After Warfarin Initiation in a Cohort of Hemodialysis Patients With Newly Diagnosed Atrial Fibrillation

Shen

Montez‐Rath

Lenihan

et al. 2015

American Journal of Kidney Diseases

125

157

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Background Although warfarin is indicated to prevent ischemic strokes in most patients with atrial fibrillation (AF), evidence supporting its use in hemodialysis is limited. Our aim was to examine outcomes after warfarin initiation, relative to no warfarin use, following incident AF in a large cohort of hemodialysis patients who had comprehensive prescription drug coverage through Medicare Part D. Study Design Retrospective observational cohort study. Setting & Participants Patients in the US Renal Data System undergoing maintenance hemodialysis who were newly diagnosed with AF in 2007-2011, with Medicare Part D coverage, who had no recorded history of warfarin use. Predictor Warfarin initiation, identified by a filled prescription within 30 days of the AF event. Outcomes Death, ischemic stroke, hemorrhagic stroke, severe gastrointestinal bleeding, and composite outcomes. Measurements HRs estimated by applying Cox regression to an inverse probability of treatment-and-censoring-weighted cohort. Results Among 12,284 patients with newly diagnosed AF, 1838 (15%) initiated warfarin within 30 days; however, ~70% discontinued its use within one year. In intention-to-treat analyses, warfarin use was marginally associated with a reduced risk of ischemic stroke (HR, 0.68; 95% CI, 0.47-0.99), but not with any of the other outcomes. In as-treated analyses, warfarin use was associated with reduced mortality (HR, 0.84; 95% CI, 0.73-0.97). Limitations Short observation period, limited number of non-fatal events, limited generalizability of results to more affluent patients. Conclusions In hemodialysis patients with incident AF, warfarin use was marginally associated with a reduced risk of ischemic stroke, and there was a signal towards reduced mortality in as-treated analyses. These results support clinical equipoise regarding the use of warfarin in HD patients and underscore the need for randomized trials to fill this evidence gap.

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Section: Discussionmentioning

confidence: 99%

Outcomes After Warfarin Initiation in a Cohort of Hemodialysis Patients With Newly Diagnosed Atrial Fibrillation

Shen

Montez‐Rath

Lenihan

et al. 2015

American Journal of Kidney Diseases

125

157

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“…OR < 1), but they may lacked statistical power to detect significant associations due to small sample size (N = 290). Given the high prevalence of frailty among HD patients [38, 39], and the high risk of adverse outcomes such as falls in this population [40, 41], physicians are reluctant to prescribe warfarin [25]. …”

Section: Discussionmentioning

confidence: 99%

“…Given the unclear survival benefit, lack of association with stroke reduction, and increased risk of bleeding associated with warfarin use in patients with ESRD [14–17], clinicians are faced with uncertainty about this treatment decision in this population [25]. Little is known about the use of warfarin in older adults with ESRD, especially about which patients are most likely to initiate this therapy after AF diagnosis and how their utilization changes after initiation.…”

Section: Introductionmentioning

confidence: 99%

Treatment of atrial fibrillation with warfarin among older adults with end stage renal disease

et al. 2017

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Background There is increasing evidence questioning the use of warfarin for atrial fibrillation (AF) among older adults with end stage renal disease (ESRD). We assessed the patterns and determinants of warfarin utilization among these patients in the US. Methods We assembled a cohort of older adults (age ≥65) undergoing dialysis with incident AF from July 2007 to November 2011 from the US Renal Data System (USRDS). We used descriptive statistics to characterize warfarin utilization within 30 days of AF discharge, and logistic regression to quantify patient characteristics associated with warfarin initiation. Results Among 5730 older adults undergoing dialysis with incident AF, 15.5% initiated warfarin. Among 2906 patients with high risk of bleeding, 12.7% initiated warfarin; whereas 14.9% initiated warfarin among 4824 patients with high risk of stroke. After adjustment for patient characteristics, warfarin initiation was lower among patients who were older [odds ratio (OR) = 0.74 per 10-year increase, 95% confidence interval (CI) 0.66–0.83] and those with a history of diabetes (OR = 0.75, 95% CI 0.63–0.90), myocardial infarction (OR = 0.64, 95% CI 0.50–0.80), or bleeding (OR = 0.63, 95% CI 0.50–0.80). There was no association between sex, race, or dialysis modality and warfarin initiation. Among patients who initiated warfarin, 46.8% discontinued warfarin use after a median treatment length of 8.6 months. Conclusion Despite the unclear benefit and increased bleeding risk of warfarin treatment in patients with ESRD, 1 in 8 older adults undergoing dialysis with incident AF in the US who had high risk of bleeding used warfarin. Changes to warfarin therapy due to discontinuation were common after initiation.

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“…However, there remains a degree of uncertainty as to the net benefit, and a rigorous RCT would provide a higher level of evidence to answer this question than the previous observational studies (55). Secondly, nephrologists and patients may have strong preferences for or against anticoagulation that may limit recruitment, although in a Canadian survey of nephrologists, the majority indicated that they would be willing to enroll their patients in such a trial (37). Finally, funding is unlikely to come from the pharmaceutical industry as generic warfarin is cheap and bioequivalent to brand-name warfarin (56), so it would likely need to be sourced publicly.…”

Section: Need For a Rctmentioning

confidence: 99%

“…A survey of 56 Canadian nephrologists found agreement in the majority (72%) that there was a state of uncertainty regarding this clinical question (37). Each nephrologist was presented six clinical scenarios and given a choice as to whether they were likely to start warfarin, unlikely to start warfarin or were uncertain.…”

Section: Uncertainty Of Warfarin Net Benefitmentioning

confidence: 99%

Anticoagulation for Atrial Fibrillation in End-stage Kidney Disease

Lee¹,

Johnson²

2015

jcbmr

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Atrial fibrillation (AF) is the most common arrhythmia in the general population and it has been found to have a higher prevalence in end-stage kidney disease (ESKD). It is associated with a higher risk of stroke and mortality compared to those without AF. Patients with ESKD have generally been excluded from randomized controlled trials (RCTs) evaluating the efficacy of anticoagulation in reduction of stroke risk. Current observational evidence for anticoagulation for AF in the ESKD population has yielded conflicting results, but in aggregate favours a lack of benefit in stroke risk reduction with an increase in bleeding risk. There are also reports that warfarin use in ESKD patients on dialysis is associated with greater International Normalised Ratio (INR) variability and increased risk of vascular calcification and calciphylaxis (uraemic calcific arteriolopathy). RCTs are required to assess the net clinical benefit of anticoagulation in this group.

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Warfarin use in hemodialysis patients with atrial fibrillation: decisions based on uncertainty

Cited by 18 publications

References 30 publications

Outcomes After Warfarin Initiation in a Cohort of Hemodialysis Patients With Newly Diagnosed Atrial Fibrillation

Outcomes After Warfarin Initiation in a Cohort of Hemodialysis Patients With Newly Diagnosed Atrial Fibrillation

Treatment of atrial fibrillation with warfarin among older adults with end stage renal disease

Anticoagulation for Atrial Fibrillation in End-stage Kidney Disease

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