Oral Anticoagulation for Patients With Atrial Fibrillation on Long-Term Hemodialysis

Toshiki Kuno, Hisato Takagi, Tomo Ando, Takehiro Sugiyama, Satoshi Miyashita, Nelson Valentin, Yuichi J. Shimada, Masaki Kodaira, Yohei Numasawa, Alexandros Briasoulis, Alfred Burger, Sripal Bangalore

Research output: Contribution to journalArticlepeer-review

61 Citations (Scopus)

Abstract

Background: Patients on long-term dialysis are at increased risk of bleeding. Although oral anticoagulants (OACs) are recommended for atrial fibrillation (AF) to reduce the risk of stroke, randomized trials have excluded these populations. As such, the net clinical benefit of OACs among patients on dialysis is unknown. Objectives: This study aimed to investigate the efficacy and safety of OACs in patients with AF on long-term dialysis. Methods: MEDLINE and EMBASE were searched through June 10, 2019, for studies that investigated the efficacy and safety of different OAC strategies in patients with AF on long-term dialysis. The efficacy outcomes were ischemic stroke and/or systemic thromboembolism, all-cause mortality, and the safety outcome was major bleeding. Results: This study identified 16 eligible observational studies (N = 71,877) regarding patients on long-term dialysis who had AF. Only 2 of 16 studies investigated direct OACs. Outcomes for dabigatran and rivaroxaban were limited to major bleeding events. Compared with no anticoagulants, apixaban and warfarin were not associated with a significant decrease in stroke and/or systemic thromboembolism (apixaban 5 mg, hazard ratio [HR]: 0.59; 95% confidence interval [CI]: 0.30 to 1.17; apixaban 2.5 mg, HR: 1.00; 95% CI: 0.52 to 1.93; warfarin, HR: 0.91; 95% CI: 0.72 to 1.16). Apixaban 5 mg was associated with a significantly lower risk of mortality (vs. warfarin, HR: 0.65; 95% CI: 0.45 to 0.93; vs. apixaban 2.5 mg, HR: 0.62; 95% CI: 0.42 to 0.90; vs. no anticoagulant, HR: 0.61; 95% CI: 0.41 to 0.90). Warfarin was associated with a significantly higher risk of major bleeding than apixaban 5 min/2.5 mg and no anticoagulant (vs. apixaban 5 mg, HR: 1.41; 95% CI: 1.07 to 1.88; vs. apixaban 2.5 mg, HR: 1.40; 95% CI: 1.07 to 1.82; vs. no anticoagulant, HR: 1.31; 95% CI: 1.15 to 1.50). Dabigatran and rivaroxaban were also associated with significantly higher risk of major bleeding than apixaban and no anticoagulant. Conclusions: This meta-analysis showed that OACs were not associated with a reduced risk of thromboembolism in patients with AF on long-term dialysis. Warfarin, dabigatran, and rivaroxaban were associated with significantly higher bleeding risk compared with apixaban and no anticoagulant. The benefit-to-risk ratio of OACs in patients with AF on long-term dialysis warrants validation in randomized clinical trials.

Original languageEnglish
Pages (from-to)273-285
Number of pages13
JournalJournal of the American College of Cardiology
Volume75
Issue number3
DOIs
Publication statusPublished - 2020 Jan 28
Externally publishedYes

Keywords

  • anticoagulant
  • atrial fibrillation
  • dialysis
  • network meta-analysis

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

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