Author + information
- Manyoo A. Agarwal, MDa,b,
- Praveen K. Potukuchi, MS, PhDc,
- Keiichi Sumida, MD, MPH, PhDc,d,
- Adnan Naseer, MDe,
- Miklos Z. Molnar, MD, PhDc,e,f,
- Lekha K. George, MDd,
- Santhosh K. Koshy, MD, MBAg,
- Elani Streja, MPH, PhDi,
- Fridtjof Thomas, PhDh,
- Kamyar Kalantar-Zadeh, MD, PhDi and
- Csaba P. Kovesdy, MDc,d,∗ ()
- aDepartment of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
- bDepartment of Internal Medicine, Division of Cardiovascular Medicine, University of California Los Angeles, Los Angeles, California
- cDivision of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee
- dNephrology Section, Memphis VA Medical Center, Memphis, Tennessee
- eMethodist University Hospital James D. Eason Transplant Institute, Memphis, Tennessee
- fDivision of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
- gDivision of Cardiovascular Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
- hDivision of Biostatistics, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
- iHarold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, California
- ↵∗Address for correspondence:
Dr. Csaba P. Kovesdy, Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, 956 Court Ave, Room B216, Memphis, TN 38103.
Objectives The aim of this study was to examine the efficacy and safety of warfarin initiation following the diagnosis of atrial fibrillation (AF) in patients with late-stage chronic kidney disease (CKD) who transitioned to dialysis.
Background The clinical benefit of warfarin therapy for thromboprophylaxis after incident AF diagnosis in patients with late-stage CKD who are transitioning to dialysis is unknown.
Methods In this retrospective cohort analysis, the study population was a national cohort of 22,771 U.S. veterans with incident end-stage renal disease who developed incident AF before initiating renal replacement therapy. This study examined the association of warfarin therapy following the diagnosis of incident AF with ischemic cerebrovascular accidents (CVAs) (ischemic stroke or transient ischemic attack), ischemic CVA−related hospitalization, major bleeding events (gastrointestinal or intracranial bleeding), bleeding event−related hospitalizations, and post-dialysis, all-cause mortality in multivariable adjusted Cox regression analyses that adjusted for demographic characteristics and comorbidities.
Results The mean ± SD age of the cohort was 73.5 ± 8.8 years, 13% were African American, and the mean CHAD2S2-VASc score was 5.7 ± 2.1. Of the overall cohort, 6,682 (29.3%) patients were started on warfarin during the follow-up period. The hazard ratios (95% confidence intervals) for ischemic CVA, bleeding events, and death for those started on warfarin were 1.23 (1.16 to 1.30), 1.36 (1.29 to 1.44), and 0.94 (0.90 to 0.97), respectively, compared with those who received no anticoagulation. Warfarin exposure was associated with higher risk for ischemic CVA and bleeding event−related hospitalizations.
Conclusions In patients with late-stage CKD who transitioned to dialysis, warfarin use was associated with higher risk of ischemic and bleeding events but a lower risk of mortality. Future studies such as those comparing warfarin with newer oral anticoagulant agents are needed to granularly define the net clinical benefit of anticoagulation therapy in patients with advanced CKD with incident AF.
This study is supported by grant 5U01DK102163 from the National Institute of Health (NIH) to Drs. Kalantar-Zadeh and Kovesdy, and by resources from the US Department of Veterans Affairs. The data reported here have been supplied by the United States Renal Data System (USRDS). Support for VA/CMS data is provided by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development, VA Information Resource Center (Project Numbers SDR 02-237 and 98-004). Drs. Kovesdy and Kalantar-Zadeh are employees of the Department of Veterans affairs. The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as official policy or interpretation of the Department of Veterans Affairs or the US government. Dr. Molnar has served as advisor for Merck and AbbVie. Dr. Kalantar-Zadeh has received honoraria and/or support from Abbott, Abbvie, Akebia, Alexion, Amgen, American Society of Nephrology, AstraZeneca, Aveo, BBraun, Chugai, Daiichi, DaVita, Fresenius, Genentech, Haymarket Media, Hofstra Medical School, International Federation of Kidney Foundations, International Society of Hemodialysis, International Society of Renal Nutrition and Metabolism, Japanese Society of Dialysis Therapy, Hospira, Kabi, Keryx, Kissei, Novartis, OPKO, National Institutes of Health, National Kidney Foundations, Pfizer, Relypsa, Resverlogix, Dr Schaer, Sandoz, Sanofi, Shire, Veterans’ Affairs, Vifor, UpToDate, and ZS-Pharma. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received September 23, 2019.
- Revision received June 22, 2020.
- Accepted June 23, 2020.
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