Atrial fibrillation and chronic kidney disease requiring hemodialysis - Does warfarin therapy improve the risks of this lethal combination?

IntroductionWarfarin therapy for stroke prevention is recommended for patients with AF, but its value in patients with chronic kidney disease on HD is unknown.MethodsThe 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 6 months or still undergoing treatment, a history of AF ablation, a history of ICD implantation, or those receiving warfarin for non-AF indications.ResultsAmong 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.ConclusionWarfarin 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.