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

Alternative 'Technical' Treatments for Atrial Fibrillation

Catheter ablation is an effective therapy for patients with symptomatic atrial fibrillation and is associated with an overall low incidence of complications.[42] It is the only treatment thus far capable of achieving a cure in a substantial proportion of patients. However, in a recent trial involving CKD patients (124 with CKD stage 2 and 36 with CKD stage 3 and higher), the authors conclude that a decreased GFR was associated with a higher recurrence rate of atrial fibrillation after successful ablation.[43] The indication, complications and outcome in patients with advanced CKD are currently largely unknown.

The left atrial appendage (LAA) is a predilection site for clot formation in atrial fibrillation.[44] Occlusion of the LAA can be achieved using standard right heart catheter techniques by crossing the interatrial septum to reach the left atrium and subsequently the LAA. In a second step, the occluder is deployed into the LAA (Figure 1).[45] Clots potentially formed in the LAA will be detained from entering the circulation. The PROTECT AF trial[46] compared closure of the LAA in 463 patients with warfarin treatment in 244 patients. The primary endpoints were the occurrence of stroke, cardiovascular or unexplained death and systemic embolism. After over 1000 patient-years of follow-up, the event rate in the intervention group was 3.0 (CI 1.9–4.5) versus 4.9 (CI 2.8–7.1) in the warfarin group. However, this difference was not significant and the occlusion procedure led to more adverse events which were attributed to the percutaneous intervention. Major bleeding and haemorrhagic strokes were higher in the warfarin control group (4.1 versus. 3.5% and 2.5 versus. 0.2%, respectively). All-cause mortality rates in the intervention group and the control group after 2 years were 5.9 and 9.1%. Whether patients with impaired kidney function were included in the trial and how these patients performed is not declared in the manuscript, but these patients were not explicitly excluded from the trial.[46] Whether this procedure is beneficial also for CKD and HD patients has to be shown in adequately powered trials.

Figure 1.

Transoesophageal ultrasound image of an occluder device (arrowheads) placed in the LAA (white contour). LA, left atrium; MV, mitral valve; LV, left ventricle. (Courtesy of A. Napp, Dept. of Cardiology, RWTH Aachen.)