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

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


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

In This Article

Atrial Fibrillation in Dialysis Patients: Incidence, Prevalence and Outcome

The prevalence of atrial fibrillation gradually increases with a decreasing GFR of 15. The CRIC study showed that atrial fibrillation occurred two to three times more often in renal patients than in non-CKD controls of the same age group.[15,16] DOPPS data from 1996 to 2004 revealed an increasing prevalence of atrial fibrillation in ESRD patients markedly exceeding that of the general population in all age groups investigated.[17]

Is atrial fibrillation in HD patients a risk factor for thromboembolic events? Conceivably, thrice weekly systemic anticoagulation with heparin during HD might protect against clot formation and thromboembolic events. Moreover, even in the absence of atrial fibrillation, spontaneous left atrial appendage thrombus formation is not unusual in dialysis patients,[18] and the risk of thromboembolic events increased with declining kidney function even before reaching ESRD.[19] A study including 19 000 pre-dialysis patients confirmed the increased incidence of venous thromboembolisms also in the absence of atrial fibrillation.[20] Consequently, the association between atrial fibrillation and stroke may differ between ESRD patients and the general population. Indeed, a retrospective analysis of 476 Italian dialysis patients between 2003 and 2006 showed increased 3-year mortality in patients with any type of atrial fibrillation compared with those without (50 versus 29%). Most of the excessive mortality was attributable to cardiac reasons (23 versus. 10%), whereas comparable numbers (15 versus. 12%) were reported for cerebral events.[21] This is in line with the observation in 430 dialysis patients where no significant difference was found between the number of patients with stroke and patients without atrial fibrillation.[22] A retrospective analysis in HD patients from 2007 revealed that participants with atrial fibrillation (n = 0) showed more cerebrovascular events and major haemorrhages than HD patients without atrial fibrillation.[23] Also, recently the mortality rate during 7 years of follow-up in incident Austrian HD patients was 52% in the atrial fibrillation (n = 52) group and 30% in patients with sinus rhythm (n = 183), whereas the incidence of bleedings and strokes did not differ.[24] In contrast, in a Spanish prospective observational trial, incident dialysis patients with atrial fibrillation (both prevalent and incident atrial fibrillation) had a 1.72-fold higher mortality and a 9.8-fold higher risk of stroke.[25]

Thus, atrial fibrillation is highly prevalent in dialysis patients and associated with increased cardiac mortality. However, data on the association between atrial fibrillation and an increased stroke risk in ESRD patients are inconsistent (Table 1).