Atrial fibrillation and warfarin use in haemodialysis patients: An individualized holistic approach is important in stroke prevention

Warfarin use and the risks of stroke and bleeding in hemodialysis patients with atrial fibrillation: A systematic review and a meta-analysis

BACKGROUND AND AIM

The efficacy and safety of warfarin therapy in hemodialysis (HD) patients with atrial fibrillation (AF) remains controversial. Thus, we performed, up to date, the first meta-analysis on the risks of stroke and bleeding in warfarin treatment in these populations.

METHODS AND RESULTS

The relevant literature was searched using the following electronic databases without any language restrictions: the Cochrane Library Database, PubMed, ISI, Ovid, and Chinese Biomedical Database from the establishment of the database to October 2014. The studies were included if (a) studies described the risk of stroke or bleeding with or without warfarin in dialysis patients with AF, (b) studies provided information about hazard ratio (HR) and 95% confidence interval (CI) of stroke or bleeding, and (c) the study design was a clinical cohort. The inverse variance method was used to obtain overall HRs and 95% CIs. Sensitivity analyses and publication bias were also performed. We identified six eligible studies with a total of 9816 patients. Combined HRs showed that warfarin cannot prevent strokes in HD patients with AF (HR = 1.23, 95% CI 0.80-1.87; P = 0.347), but its use was associated with a higher risk of bleeding (HR = 1.20, 95% CI 1.03-1.39; P = 0.019).

CONCLUSION

This meta-analysis suggested that warfarin should not be recommended for the routine treatment of HD patients with AF.

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.