Antiplatelet medications in hemodialysis patients: a systematic review of bleeding rates.
OBJECTIVE
Patients with end stage renal disease (ESRD) are often prescribed antiplatelet medications. However, these patients are also at increased risk of bleeding compared with the general population, and an aim was made to quantify this risk with antiplatelet agents.


METHODS
A systematic review of the literature (Medline, EMBASE, Cochrane CENTRAL and Google Scholar databases) was done to determine the bleeding risk in ESRD patients prescribed antiplatelet therapy. The secondary outcome was the effect on access thrombosis. All case series, cohort studies and clinical trials were considered if they included ten or more ESRD patients, assessed bleeding risk with antiplatelet agents, and lasted for more than 3 mo.


RESULTS
Sixteen studies, including 40,676 patients, were identified that met predefined inclusion criteria. Due to study heterogeneity and weaknesses in methodology, bleeding rates were not pooled across studies. However, the bleeding risk appears to be increased for hemodialysis patients treated with combination antiplatelet therapy. The results are mixed for studies using a single antiplatelet agent. Antiplatelet agents appear to be effective in preventing shunt and central venous catheter thrombosis, but not for preventing thrombosis of arteriovenous grafts.


CONCLUSIONS
The risks and benefits of antiplatelet agents in ESRD patients remain poorly defined. Until a clinical trial addresses this in the dialysis population, individual risk stratification taking into account the increased risk of bleeding should be considered before initiating antiplatelet agents, especially in combination therapy.
Hiremath
Swapnil
S
Division of Nephrology, University of Ottawa, Kidney Research Centre, Ottawa, Ontario, Canada. shiremath@toh.on.ca
Holden
Rachel M
RM
Fergusson
Dean
D
Zimmerman
Deborah L
DL
D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects; D002405:Catheterization, Central Venous / Q000009:adverse effects; D004359:Drug Therapy, Combination; D006470:Hemorrhage / Q000139:chemically induced*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000097:blood / Q000188:drug therapy / Q000628:therapy*; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects*; D006435:Renal Dialysis / Q000009:adverse effects*; D018570:Risk Assessment; D013927:Thrombosis / Q000209:etiology / Q000517:prevention & control*; D016896:Treatment Outcome
D010975:Platelet Aggregation Inhibitors