title: Treatment of atrial fibrillation with warfarin among older adults with end stage renal disease.
abstract: BACKGROUND
  There is increasing evidence questioning the use of warfarin for atrial fibrillation (AF) among older adults with end stage renal disease (ESRD). We assessed the patterns and determinants of warfarin utilization among these patients in the US.
  
  
  METHODS
  We assembled a cohort of older adults (age ≥65) undergoing dialysis with incident AF from July 2007 to November 2011 from the US Renal Data System (USRDS). We used descriptive statistics to characterize warfarin utilization within 30 days of AF discharge, and logistic regression to quantify patient characteristics associated with warfarin initiation.
  
  
  RESULTS
  Among 5730 older adults undergoing dialysis with incident AF, 15.5% initiated warfarin. Among 2906 patients with high risk of bleeding, 12.7% initiated warfarin; whereas 14.9% initiated warfarin among 4824 patients with high risk of stroke. After adjustment for patient characteristics, warfarin initiation was lower among patients who were older [odds ratio (OR) = 0.74 per 10-year increase, 95% confidence interval (CI) 0.66-0.83] and those with a history of diabetes (OR = 0.75, 95% CI 0.63-0.90), myocardial infarction (OR = 0.64, 95% CI 0.50-0.80), or bleeding (OR = 0.63, 95% CI 0.50-0.80). There was no association between sex, race, or dialysis modality and warfarin initiation. Among patients who initiated warfarin, 46.8% discontinued warfarin use after a median treatment length of 8.6 months.
  
  
  CONCLUSIONS
  Despite the unclear benefit and increased bleeding risk of warfarin treatment in patients with ESRD, 1 in 8 older adults undergoing dialysis with incident AF in the US who had high risk of bleeding used warfarin. Changes to warfarin therapy due to discontinuation were common after initiation.
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615, N. Wolfe St, W6033, Baltimore, MD, 21205, USA.|Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
authors.forename: Jingwen
authors.identifier: http://orcid.org/0000-0002-4965-6911
authors.initials: J
authors.lastname: Tan
authors.affiliation: Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
authors.forename: Sunjae
authors.initials: S
authors.lastname: Bae
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615, N. Wolfe St, W6033, Baltimore, MD, 21205, USA.|Center for Drug Safety and Effectiveness,, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.|Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.|Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Jodi B
authors.initials: JB
authors.lastname: Segal
authors.affiliation: Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Junya
authors.initials: J
authors.lastname: Zhu
authors.affiliation: Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
authors.forename: Dorry L
authors.initials: DL
authors.lastname: Segev
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615, N. Wolfe St, W6033, Baltimore, MD, 21205, USA.|Center for Drug Safety and Effectiveness,, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.|Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
authors.forename: G Caleb
authors.initials: GC
authors.lastname: Alexander
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615, N. Wolfe St, W6033, Baltimore, MD, 21205, USA. mara@jhu.edu.|Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA. mara@jhu.edu.|Center for Drug Safety and Effectiveness,, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. mara@jhu.edu.
authors.forename: Mara
authors.initials: M
authors.lastname: McAdams-DeMarco
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000009:adverse effects*; D001281:Atrial Fibrillation / Q000188:drug therapy*; D015331:Cohort Studies; D005260:Female; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications*; D008297:Male; D014859:Warfarin / Q000009:adverse effects*
chemical_list: D000925:Anticoagulants; D014859:Warfarin
keywords: Anticoagulants; Atrial fibrillation; Drug utilization; End stage renal disease; Warfarin