September 1, 2007

Should Hemodialysis Patients With Atrial Fibrillation Undergo Systemic Anticoagulation? A Cost-Utility Analysis.

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  • Rob Quinn

    That’s a great question and two interesting articles. In my opinion, they reinforce our conclusion that we are lacking important information about the risk of stroke in dialysis patients with atrial fibrillation, the efficacy of warfarin in reducing the risk of stroke, and the bleeding risk associated with warfarin use. It argues strongly for clinical trials in this population so that we can adequately inform decision-making.

    To address your question specifically, the bleeding risks outlined in the Elliott paper are within the range considered in our analysis. If you believe existing data on the risk of stroke and that warfarin reduces the risk of stroke in dialysis patients to the same degree that it has been shown to in the general population, warfarin would be the best strategy based on existing data.

    I only have access to the abstract from the To paper at the moment, but they report a risk of major bleeding that is three times the risk of cerebrovascular accidents. Under situations where the risk of stroke is similar in Afib and non-afib groups of dialysis patients, and the risk of bleeding is high, Warfarin is still the optimal strategy given the assumptions above.

    The purpose of using decision analysis to examine this question was to really take a hard look at what drives decision making and patient outcomes. Strokes can have devastating consequences that, if a patient survives, have a significant impact on quality of life long-term. Major bleeding episodes, while serious, have a much lower mortality rate. If you survive, you generally are not left with residual disability, and so quality of life isn’t impacted for very long. This is why the results seem so robust to changes in the bleeding rates. There is also some interesting work done by Devereaux et al that suggests patients are much more tolerant of serious bleeding events in order to prevent strokes (Devereaux PJ, et al BMJ 2001 323:1-7) than physicians are. There is a limit to this, however and that’s why it would be important to gather better information about bleeding rates.

    This brings me back to my initial comment. We need to know the risks and benefits of treatment with warfarin in this population in order to adequately inform patient and physician decision-making. There are significant enough differences between dialysis patients and the general population that we can’t simply “borrow” data from randomized trials that were done in a highly selected group. I think this area requires more investigation and more debate. I hope our article will stimulate that.

  • Visitor

    For those of you with full text access to AJKD, there is an interesting editorial that accompanies this article:

  • Visitor

    Dr. Quinn,

    There are 2 recent papers (1 in the same AJKD issue your paper was published in) that discuss the risk of bleeding in dialysis patients who receive anticoagulation:

    Meghan J. Elliott, Deborah Zimmerman, Rachel M. Holden
    Warfarin Anticoagulation in Hemodialysis Patients: A Systematic Review of Bleeding Rates
    AJKD Volume 50, Issue 3, Pages 433-440 (September 2007)

    Atrial fibrillation in haemodialysis patients: Do the guidelines for anticoagulation apply?
    Nephrology October 2007 – Vol. 12 Issue 5 pages 441–447

    Does this new information affect your conclusions in any way?