Abstract
BackgroundThere is conflicting evidence of benefit versus harm for warfarin anticoagulation in hemodialysis patients with atrial fibrillation. This equipoise may be explained by suboptimal Time in Therapeutic Range (TTR), which correlates well with thromboembolic and bleeding complications. This study aimed to compare nephrologist-led management of warfarin therapy versus that led by specialized anticoagulation clinic.MethodsIn a retrospective cohort of chronic hemodialysis patients from two institutions (Institution A: Nephrologist-led warfarin management, Institution B: Anticoagulation clinic-led warfarin management), we identified patients with atrial fibrillation who were receiving warfarin for thromboembolic prophylaxis. Mean TTRs, proportion of patients achieving TTR ≥ 60%, and frequency of INR testing were compared using a logistic regression model.ResultsIn Institution A, 16.7% of hemodialysis patients had atrial fibrillation, of whom 36.8% were on warfarin. In Institution B, 18% of hemodialysis patients had atrial fibrillation, and 55.5% were on warfarin. The mean TTR was 61.8% (SD 14.5) in Institution A, and 60.5% (SD 15.8) in Institution B (p-value 0.95). However, the proportion of patients achieving TTR ≥ 60% was 65% versus 43.3% (Adjusted OR 2.22, CI 0.65–7.63) and mean frequency of INR testing was every 6 days versus every 13.9 days in Institutions A and B respectively.ConclusionsThere was no statistical difference in mean TTR between nephrologist-led management of warfarin and that of clinic-led management. However, the former achieved a trend toward a higher proportion of patients with optimal TTR. This improved therapeutic results was associated with more frequent INR monitoring.
Highlights
There is conflicting evidence of benefit versus harm for warfarin anticoagulation in hemodialysis patients with atrial fibrillation
Study design and settings This is a retrospective cohort study of chronic hemodialysis patients with atrial fibrillation receiving warfarin for the prevention of thromboembolic complications of atrial fibrillation in two university teaching hospitals; the McGill University Health Centre (MUHC) and the Jewish General Hospital (JGH), both located in Montreal, Canada
At the MUHC, warfarin-based anticoagulation is managed by nephrologists, whereas at the JGH it is managed through an anticoagulation clinic led by hematologists
Summary
There is conflicting evidence of benefit versus harm for warfarin anticoagulation in hemodialysis patients with atrial fibrillation. This equipoise may be explained by suboptimal Time in Therapeutic Range (TTR), which correlates well with thromboembolic and bleeding complications. The risk of thromboembolic events is even higher in patients with advanced chronic kidney disease, when compared to the general population leading to a higher morbidity and mortality in this. The Kidney Disease: Improving Global Outcomes, guidelines state that routine anticoagulation of stage 5 chronic kidney disease patients with atrial fibrillation for primary prevention of stroke is not indicated [13]. This study showed that an improved TTR was correlated with lower risk of hemorrhage. It is possible that the advantages of warfarin are not demonstrated in hemodialysis patients, in part, due to the suboptimal TTRs
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