Sailing Between Scylla and Charybdis: Oral Long-term Anticoagulation in Dialysis Patients

Thilo Krüger; Vincent Brandenburg; Georg Schlieper; Nikolaus Marx; Jürgen Floege

Disclosures

Nephrol Dial Transplant. 2013;28(3):534-541. 

In This Article

Indications and Contraindications for Long-term Anticoagulation in Patients on Dialysis

Several clinical scenarios require long-term oral anticoagulation treatment (OAT) in both the general population as well as in patients with chronic kidney disease (CKD) and ESRD (see below). In the general population, atrial fibrillation also requires long-term OAT therapy, if certain risk factors are present. This recommendation in the international guidelines is supported by large-scale clinical trials in the general (non-renal) population.[9] However, such a clear evidence basis is lost for patients with moderate-to-advanced CKD and is absent in patients with ESRD. Given this lack of evidence, the current European Society of Cardiology (ESC) guideline does not give any recommendations and simply states the following: 'Thus, CKD may increase the risk of thromboembolism in atrial fibrillation, although such patients are also at increased mortality and bleeding risk and have not been studied in prospective clinical trials'.[9]

We suggest separating the scenario of OAT in advanced CKD or ESRD into three categories:

  1. We generally recommend OAT in CKD or ESRD patients in analogy to the general population in the following situations: patients with pulmonary embolism, deep vein thrombosis and mechanical cardiac valve replacement. Similarly, antiphospholipid antibody syndrome is also likely to require long-term OAT in CKD or ESRD patients. There is, however, no clear evidence available about the optimal length of OAT in CKD or ESRD patients with single, idiopathic thromboembolic events.

  2. OAT is generally not recommended for acute or recurrent fistula occlusions or dialysis catheter dysfunction. Thus, a limited number of reports support the hypothesis that systemic anticoagulation does not reduce catheter complications or at least does not outweigh the risk of bleeding complications.[10–12] In one randomized trial investigating the time to shunt occlusion, coumarin treatment was not superior to no treatment; however, 10% of all coumarin-treated patients exhibited relevant bleeding events compared with none in the control group.[13] Data from the DOPPS (Dialysis Outcomes and Practice Patterns Study) database even showed reduced patency rates using coumarins compared with the control,[14] but residual confounding-by-indication cannot be fully excluded in such analyses.

  3. The decision whether or not to apply OAT should be based on an individualized risk-benefit approach. This largely includes advanced CKD and ESRD patients with atrial fibrillation.

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