The intersection of risk and benefit: is warfarin anticoagulation suitable for atrial fibrillation in patients on hemodialysis?
The risks and benefits of anticoagulation for stroke prevention with atrial fibrillation is clearly delineated in the general population. Little evidence exists for patients with end-stage renal disease (ESRD) about whether the extrapolation of these guidelines is appropriate. In patients with ESRD who are undergoing hemodialysis, the rates for both stroke and bleeding are 3 to 10 times higher than that for the general population. Furthermore, the proportion of hemorrhagic to ischemic strokes has increased, making the decision of whether to initiate anticoagulation problematic. In this commentary, we discuss the existing literature for stroke in atrial fibrillation, stroke type, risk reduction with anticoagulation, and bleeding risks in the hemodialysis population. We comment on validated risk stratification models of stroke prevention and bleeding and their applicability to patients undergoing hemodialysis. Finally, we recommend treatment strategies that are based on the existing state of knowledge.
Sood
Manish M
MM
Department of Medicine, Winnipeg, MB, Canada; St. Boniface General Hospital, Winnipeg, MB, Canada. Electronic address: msood@sbgh.mb.ca.
Komenda
Paul
P
Department of Medicine, Winnipeg, MB, Canada; St. Boniface General Hospital, Winnipeg, MB, Canada.
Sood
Amy R
AR
Department of Pharmacy, Winnipeg, MB, Canada; St. Boniface General Hospital, Winnipeg, MB, Canada.
Rigatto
Claudio
C
Department of Medicine, Winnipeg, MB, Canada; St. Boniface General Hospital, Winnipeg, MB, Canada.
Bueti
Joe
J
Department of Medicine, Winnipeg, MB, Canada; Health Sciences Centre, Winnipeg, MB, Canada.
D000925:Anticoagulants / Q000009:adverse effects* / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000188:drug therapy*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications; D006435:Renal Dialysis; D020521:Stroke / Q000517:prevention & control; D014859:Warfarin / Q000009:adverse effects* / Q000627:therapeutic use*
D000925:Anticoagulants; D014859:Warfarin