Original Investigation
Oral Anticoagulation for Patients With Atrial Fibrillation on Long-Term Dialysis

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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.

Key Words

anticoagulant
atrial fibrillation
dialysis
network meta-analysis

Abbreviations and Acronyms

AF
atrial fibrillation
CI
confidence interval
DOAC
direct oral anticoagulant
ESKD
end-stage kidney disease
HR
hazard ratio
OAC
oral anticoagulant

Cited by (0)

Dr. Shimada is supported in part by unrestricted grants from the American Heart Association National Clinical and Population Research Award and Career Development Award, Honjo International Scholarship Foundation, and Korea Institute of Oriental Medicine. Dr. Bangalore is supported by grants from Abbott Vascular and the National Heart, Lung, and Blood Institute; and is a member of the Advisory Board of Abbott Vascular, Biotronik, Amgen, Pfizer, and Reata. Dr. Burger holds stock in Potola Pharmaceutical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Louise Pilote, MD, MPH, PhD, served as Guest Associate Editor for this paper.

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