Anticoagulation for stroke prevention in patients with atrial fibrillation on hemodialysis is associated with net-clinical harm

Objective Evidence supporting the use of anticoagulation for the prevention of stroke and thromboembolism in patients with kidney failure on hemodialysis (HD) and atrial fibrillation (AF) is limited. Patients on HD patients are at high risk of stroke, but also particularly prone to bleeding. We prospectively assessed the incidences of stroke and major bleeding, as well as anticoagulation strategies in HD patients with AF.

Material and Methods We recruited 625 prevalent HD patients into a population-based cohort study. Patients were prospectively followed for the occurrence of thromboembolic events (stroke, TIA, systemic embolism), and for major bleeding. Secondary outcomes were 3P-MACE (myocardial infarction, stroke, and cardiovascular death), and a composite outcome of stroke, TIA, systemic embolism, major bleeding and cardiovascular death to determine net-clinical harm.

Results Of the 625 patients, 238 (38.1 %) had AF, 165 (26.4 %) already at baseline and 73 (15.9 %) developed AF during follow of up (median follow up 870 days). 40 (6.4 %) thromboembolic events, 89 (14.2 %) major bleedings, and 154 (24.6 %) 3P-MACE events occurred. Overall, 256 patients died (41.0 %), including 105 patients (16.8 %) from a cardiovascular cause. The incidence and case-fatality rates of all outcomes was higher in AF patients compared to non-AF patients.

In AF patients, use of vitamin K antagonists (VKA) in 61 patients (25.6 %) and low-molecular weight heparin (LMWH) on non-HD days in 38 patients (16.0 %) was not associated with significantly reduced risk of the primary outcome (SHR adjusted for CHA2DS2-VASc score and antiplatelet co-medication 1.41, 95 % confidence interval [CI] 0.49–4.07, and SHR 0.49, 95 % CI 0.11–2.18, respectively), but VKA was associated with significantly increased risk of major bleeding compared to AF patients not receiving anticoagulation (N = 139, 58.4 %). Use of VKA was associated with net-clinical harm (adjusted SHR 2.07 95%CI 1.25–3.42).

Conclusion Stroke and major bleeding are common complications in HD patients, especially in those with AF. Anticoagulation with VKA was not associated with decreased thromboembolic risk, but increased major bleeding and may be net-harmful to patients with AF on HD.

Publication History

Article published online:
18 June 2021