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

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, CHA2DS2-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.

The risk of bleeding for antiplatelet agents in Haemodialysis patients: a Meta-analysis

Background

The safety of antiplatelet therapy in haemodialysis (HD) patients remains controversial. we conducted the first meta-analysis to evaluate the bleeding risk with antiplatelet agents in these populations.

Methods

The relevant literature was searched using the following electronic databases without any language restrictions: the Cochrane Library, EMBASE, Global Health, MEDLINE, PubMed, and the Chinese Biomedical Database.

Results

Seven randomized controlled trials (RCTs) and 2 prospective cohort studies, consisting of 1131 patients, were identified for detailed evaluation. The meta-analysis suggested that the use of double antiplatelet agents increased the risk of bleeding in HD patients [odds ratio (OR) = 2.78; 95% confidence interval (CI) 1.63 to 4.76; I² = 0], and antiplatelet agents increased the risk of bleeding in 7 RCTs [odds ratio (RR) = 1.40, 95% CI 1.08 to 1.79; I² = 23%,]; however, the use of a single antiplatelet agent was not found to significantly increase the risk of bleeding (RR = 0.88; 95% CI 0.51 to 1.50; I² = 0).

Conclusion

The results suggested that the use of double antiplatelet agents increased the risk of bleeding in HD patients.

Adverse Effect of Antithrombotic Medications on Bleeding Events and Comparison of Antithrombotic Agents in Hemodialysis Patients

Antithrombotic medications (AM) are mandatory for many hemodialysis patients, but the bleeding risk associated with this therapy is elevated. The frequency of bleeding events requiring discontinuation of AM, cessation of heparin use, and/or hospitalization was compared between hemodialysis patients with and without AM. All the hemodialysis patients in our clinic were investigated. AM were prescribed in 130 of 222 patients. Except for patients with cilostazol, those with AM had significantly more frequent bleeding events than those without AM (P < 0.01). Bleeding event frequency per 10 000 days of aspirin, clopidogrel, cilostazol, and warfarin prescription was 7.37, 5.95, 2.41, and 9.81, respectively, when restricted to administration of a single AM, which was 4.96, 2.87, 0.7, and 16.06, respectively. In patients without AM, it was 0.91. The bleeding risk associated with AM is elevated in hemodialysis patients and differs markedly depending on the agent used, with the lowest risk associated with cilostazol.

Different impact of aspirin on renal progression in patients with predialysis advanced chronic kidney disease with or without previous stroke

BACKGROUND

The benefit of reducing the risk of stroke against increasing the risk of renal progression associated with antiplatelet therapy in patients with advanced chronic kidney disease (CKD) is controversial.

METHODS

We enrolled 1301 adult patients with advanced CKD treated with erythropoiesis stimulating agents from January 1, 2002 to June 30, 2009 from the 2005 Longitudinal Health Insurance Database in Taiwan. All of the patients were followed until the development of the primary or secondary endpoints, or the end of the study (December 31, 2011). The primary endpoint was the development of ischemic stroke, and the secondary endpoints included hospitalization for bleeding events, cardiovascular mortality, all-cause mortality, and renal failure. The adjusted cumulative probability of events was calculated using multivariate Cox proportional regression analysis.

RESULTS

Adjusted survival curves showed that the usage of aspirin was not associated with ischemic stroke, hospitalization for bleeding events, cardiovascular mortality or all-cause mortality, however, it was significantly associated with renal failure. In subgroup analysis, aspirin use was associated with renal failure in the patients with no history of stroke (HR, 1.41; 95% CI, 1.14-1.73), and there was a borderline interaction between previous stroke and the use of aspirin on renal failure (interaction p=0.0565).

CONCLUSIONS

There was no significant benefit in preventing ischemic stroke in the patients with advanced CKD who received aspirin therapy. Furthermore, the use of aspirin was associated with the risk of renal failure in the patients with advanced CKD without previous stroke.

Anticoagulation in Chronic Hemodialysis: Progress Toward an Optimal Approach

Appropriate anticoagulation for hemodialysis (HD) requires a subtle balance between under- and over-heparinization to prevent extracorporeal circuit (ECC) clotting and bleeding, respectively. We discuss five key issues relating to anticoagulation therapy for chronic HD in adults following a review of relevant literature published since 2002: (i) options for standardization of anticoagulation in HD settings. The major nephrology societies have issued low evidence level recommendations on this subject. Interventional studies have generally investigated novel low-molecular weight heparins and provided data on safety of dosing regimens that cannot readily be extrapolated to clinical practice; (ii) identification of clinical and biological parameters to aid individualization of anticoagulation treatment. We find that use of clinical and biological monitoring of anticoagulation during HD sessions is currently not clearly defined in routine clinical practice; (iii) role of ECC elements (dialysis membrane and blood lines), dialysis modalities, and blood flow in clotting development; (iv) options to reduce or suppress systemic heparinization during HD sessions. Alternative strategies have been investigated, especially when the routine mode of anticoagulation was not suitable in patients at high risk of bleeding or was contraindicated; (v) optimization of anticoagulation therapy for the individual patient. We conclude by proposing a standardized approach to deliver anticoagulation treatment for HD based on an individualized prescription prepared according to the patient's profile and needs.

Anticoagulant and antiplatelet therapy in patients with chronic kidney disease: risks versus benefits review

PURPOSE OF REVIEW

Atrial fibrillation and cardiovascular death are increased in end-stage renal disease (ESRD) patients compared to the general population. The effect of anticoagulant and antiplatelet medications for these indications in ESRD is unclear. However, both classes of medications have been used for the preservation of vascular access. This review explores the risks and benefits of anticoagulant and antiplatelet medications in ESRD.

RECENT FINDINGS

ESRD patients with atrial fibrillation have a two and three-fold greater risk of death and stroke, respectively, than ESRD patients without atrial fibrillation. Warfarin does not appear to decrease this risk, and increases the risk of bleeding and vascular calcification. Warfarin also does not appear to be effective for vascular access preservation. In a few large observational studies, antiplatelet agents did not decrease the risk of cardiovascular death, but confounding by indication is likely. Antiplatelet agents do appear to prolong unassisted arteriovenous graft patency, but the effect is modest.

SUMMARY

The role of anticoagulant and antiplatelet agents for atrial fibrillation and cardiovascular disease in ESRD remains unclear. Well designed randomized controlled trials to determine the role of anticoagulation in ESRD patients with atrial fibrillation, and anticoagulant and antiplatelet medications in the preservation of central venous catheter function are required.

Effectiveness and Safety of Antiplatelet in Stroke Patients with End-Stage Renal Disease Undergoing Dialysis

Background

Antiplatelet therapy is known to decrease the risk of secondary ischemic stroke. However, the effectiveness and safety of antiplatelet therapy in patients with end-stage renal disease are uncertain, especially in dialysis.

Aims and/or hypothesis

We estimated the effectiveness and safety of antiplatelet drugs (aspirin and clopidogrel) for the prevention of recurrent ischemic stroke in end-stage renal disease patients undergoing dialysis during long-term follow-up after first-time ischemic stroke.

Methods

The cases were identified from the National Health Insurance Research Database. Antiplatelet therapy was administered for 11 years to patients experiencing a first ischemic stroke between 1998 and 2006. Primary outcomes, including death and readmission to hospital for stroke, and secondary outcomes, including death, stroke, and acute myocardial infarction or bleeding, were examined.

Results

In total, 1936 patients experienced a first ischemic stroke during the follow-up. In a time-dependent analysis, the hazard ratio for primary outcomes in patients treated with aspirin was 0·671 ( P < 0·001) and that for clopidogrel was 0·933 ( P = 0·497). At secondary outcomes, patients treated with aspirin, hazard ratio for readmission for stroke was 0·715 ( P = 0·002) and that for bleeding was 0·885 ( P = 0·291). Independent risk factors for mortality and readmission due to ischemic stroke included age, diabetes mellitus, and administration of proton pump inhibitors.

Conclusions

Antiplatelet therapy, especially aspirin, still offers safe and effective treatment for ischemic stroke prevention in patients with end-stage renal disease undergoing dialysis.

Prevalence of gastrointestinal and psychosomatic symptoms among Asian patients undergoing regular hemodialysis

AIM

Gastrointestinal (GI) symptoms are reported to be common among patients with chronic disorders including end-stage renal disease (ESRD). This questionnaire study assessed the prevalence of GI symptoms among patients undergoing hemodialysis (HD) and to correlate with the presence of diabetes mellitus and psychosomatic symptoms in Asian patients with ESRD.

METHODS

A total of 123 patients (male 47.2%) participated in this study. GI symptoms (upper GI: anorexia, nausea, vomiting, odynophagia, dysphagia, early satiety, heartburn, dyspepsia and lower GI: abdominal bloating, non-epigastrium abdominal pain, bowel habit and bleeding per rectum) and psychosomatic symptoms (anxiety, backache, depression, headache and insomnia) in the previous 12 months were enquired and compared with age and gender matched controls (n = 197).

RESULTS

The mean age of patients was 51.8 ± 12.9 years with mean duration of HD of 28 ± 38.2 months. Overall, 70.7% of ESRD patients had experienced any GI symptoms; upper GI, 65% and lower GI, 34.1%, significantly more than controls (P < 0.05). ESRD patients had more anorexia, nausea, vomiting, dyspepsia, irregular bowel habit and bleeding per rectum (all P < 0.05). Overlap of upper and lower GI symptoms was reported by 34.1%, significantly higher than control (14.2%, P < 0.05). ESRD patients also experienced significantly more anxiety, depressive symptoms and insomnia (all P < 0.05). Among the patients with ESRD, the presence of any psychosomatic symptoms correlated significantly with the presence of any upper or lower GI symptoms and overlapping of GI symptoms. Such correlations were not seen with diabetes mellitus.

CONCLUSION

Gastrointestinal and psychosomatic symptoms are common among our Asian patients with ESRD undergoing regular HD. The presence of underlying psychosomatic symptoms but not diabetes mellitus correlated significantly with the presence of GI symptoms.