title: Atrial fibrillation and chronic kidney disease requiring hemodialysis - Does warfarin therapy improve the risks of this lethal combination?
abstract: BACKGROUND
  Warfarin therapy for stroke prevention is recommended for patients with AF, but its value in patients with chronic kidney disease on HD is unknown.
  
  
  METHODS
  The anticoagulation regimens of patients with a prior history of AF hospitalized for initiation of chronic HD, and of patients receiving chronic HD who had a new diagnosis of AF between 2009 and 2012 were reviewed. Exclusions were renal transplant, peritoneal dialysis, rheumatic valve disease, prosthetic heart valve, GI bleeding, malignancy with chemotherapy in last 6months or still undergoing treatment, a history of AF ablation, a history of ICD implantation, or those receiving warfarin for non-AF indications.
  
  
  RESULTS
  Among 302 patients included in the study, 119 (39%) were prescribed warfarin and 183 (61%) were not. The two groups were similar regarding demographics, and prevalence of comorbidities including diabetes, heart failure, coronary artery disease, hypertension, use of antiplatelet agents and prior stroke. Warfarin use did not lower risk for ischemic stroke (HR 0.93; 95% CI 0.49-1.82, P=0.88) or improve overall survival (HR 1.02; 95% CI 0.91-1.15, P=0.62), but trended toward higher risk of bleeding complications (HR 1.53; 95% CI 0.94-2.51, P=0.086) after adjusting for potential confounders.
  
  
  CONCLUSIONS
  Warfarin use was not associated with reduction in stroke risk or mortality in patients with AF on chronic HD, but trended toward greater bleeding risk. The benefit of warfarin therapy in these patients may be outweighed by its risks.
authors.affiliation: Dept. of Internal Medicine, Beaumont Health, Royal Oak, MI 48073, USA. Electronic address: garg.medicine@gmail.com.
authors.forename: Lohit
authors.initials: L
authors.lastname: Garg
authors.affiliation: Dept. of Biostatistics, Beaumont Health, Royal Oak, MI 48073, USA.
authors.forename: Charity
authors.initials: C
authors.lastname: Chen
authors.affiliation: Dept. of Electrophysiology/Cardiology, Beaumont Health, Royal Oak, MI 48073, USA.
authors.forename: David E
authors.initials: DE
authors.lastname: Haines
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000188:drug therapy / Q000401:mortality; D015331:Cohort Studies; D015897:Comorbidity; D005260:Female; D006470:Hemorrhage / Q000139:chemically induced / Q000453:epidemiology; D006801:Humans; D008297:Male; D006435:Renal Dialysis / Q000379:methods; D051436:Renal Insufficiency, Chronic / Q000453:epidemiology / Q000628:therapy; D018570:Risk Assessment / Q000379:methods; D012307:Risk Factors; D020521:Stroke / Q000175:diagnosis / Q000453:epidemiology; D016019:Survival Analysis; D014481:United States / Q000453:epidemiology; D014859:Warfarin / Q000008:administration & dosage / Q000009:adverse effects
chemical_list: D000925:Anticoagulants; D014859:Warfarin
keywords: Atrial fibrillation; Bleeding; Hemodialysis; Stroke prevention; Warfarin