title: Meta-Analysis of Anticoagulation Use, Stroke, Thromboembolism, Bleeding, and Mortality in Patients With Atrial Fibrillation on Dialysis.
abstract: Atrial fibrillation (AF) is common in patients on dialysis. Although randomized trials of anticoagulation for AF have demonstrated striking reductions in stroke, these trials did not recruit patients on dialysis. We thus undertook this systematic review and meta-analysis of observational studies including patients with AF on dialysis that reported associations of anticoagulation use. Twenty studies involving 529,741 subjects and 31,321 patients with AF on dialysis were identified. Anticoagulation was associated with a 45% (95% CI 13% to 88%) increased risk of any stroke, reflecting a nonsignificant 13% (95% CI -4% to 34%) increased ischemic stroke risk and 38% (95% CI 3% to 85%) increased hemorrhagic stroke risk. There was also a 44% (95% CI 38% to 56%) lower risk of any thromboembolism, and a 31% (95% CI 12% to 53%) increased risk of any bleeding but no clear association with cardiovascular death (relative risk 0.99, 95% CI 0.86 to 1.15) or all-cause mortality (relative risk 0.97, 95% CI 0.90 to 1.04). Incident event rates were similar or worse in patients on anticoagulation. In conclusion, these observational analyses provide little supporting evidence of benefit, and instead suggest harm, from anticoagulation in patients on dialysis with AF. These results raise the possibility that the effects of anticoagulation in patients with AF on dialysis may not be similar to the clear benefit of anticoagulation seen in patients with AF without end-stage renal disease. Randomized trials are required to definitively evaluate the safety and efficacy of anticoagulation for AF in the dialysis setting.
authors.affiliation: Nuffield Department of Population Health, Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, United Kingdom; School of Medicine, Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia. Electronic address: christopher.wong@ctsu.ox.ac.uk.
authors.forename: Christopher X
authors.initials: CX
authors.lastname: Wong
authors.affiliation: Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Ayodele
authors.initials: A
authors.lastname: Odutayo
authors.affiliation: Oxford Martin School, George Institute for Global Health, University of Oxford, Oxford, United Kingdom.
authors.forename: Connor A
authors.initials: CA
authors.lastname: Emdin
authors.affiliation: Department of Surgery, Lyell McEwin Hospital, Adelaide, Australia.
authors.forename: Ned J
authors.initials: NJ
authors.lastname: Kinnear
authors.affiliation: Churchill Hospital, Oxford University Hospitals National Health Service Trust, Oxford, United Kingdom.
authors.forename: Michelle T
authors.initials: MT
authors.lastname: Sun
mesh_terms: D000925:Anticoagulants / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000150:complications / Q000401:mortality / Q000628:therapy; D014943:Global Health; D006801:Humans; D015994:Incidence; D007676:Kidney Failure, Chronic / Q000150:complications* / Q000453:epidemiology / Q000628:therapy; D006435:Renal Dialysis; D012307:Risk Factors; D020521:Stroke / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D015996:Survival Rate / Q000639:trends; D013923:Thromboembolism / Q000209:etiology / Q000517:prevention & control*
chemical_list: D000925:Anticoagulants