Bleeding Risk Outweighs Stroke Risk in ESRD Patients With AFib

The following article features coverage from the National Kidney Foundation’s 2019 Spring Clinical Meetings. Click here to read more of Renal & Urology News’ conference coverage.

Patients with end-stage renal disease (ESRD) who have pre-existing atrial fibrillation (AFib) may risk greater harm from continuing rather than halting anticoagulation therapy after dialysis transition, study findings presented at the National Kidney Foundation’s 2019 Spring Clinical Meetings in Boston suggest.

Kamyar Kalantar-Zadeh, MD, MPH, PhD, of the University of California Irvine School of Medicine, and collaborators compared the risk for stroke against the risk for bleeding in 24,383 AFib patients (all veterans) transitioning to dialysis using CHA₂SD₂-VASc and HAS-BLED risk calculators, respectively. About 17% of patients were taking antiplatelet or anticoagulant medication at transition. The investigators used claims data to identify stroke and bleeding events and other pertinent information.

The risk calculators proved predictive in this population. Higher HAS-BLED scores and higher CHA₂DS₂-VASc scores indicated higher bleeding and stroke risk, respectively. However, even a low HAS-BLED score of 0 was associated with a high risk for bleeding (5.6 per 100 patient-years). The highest CHA₂DS₂-VASc scores of 8 to 9 were associated with lower risk for stroke, at most 4.8 per 100 patient-years. Outcomes did not differ according medication use.

Higher CHA₂DS₂-VASc scores also predicted early mortality. Older women with cerebrovascular disease, hypertension, and congestive heart failure tended to have higher scores.

To date, the risk calculators have not been validated in the US dialysis population.

“For patients with preexisting atrial fibrillation who transition to dialysis, traditional risk calculators such as the HAS-BLED and the CHA₂DS₂-VASc scores should be re-evaluated,” Dr Kalantar-Zadeh told Renal & Urology News. “Continuation of anticoagulation may be associated with higher risk of severe bleeding relative to risk of stroke. Clinicians should perform a risk/benefit evaluation of anticoagulation continuation for primary stroke prevention at the time of dialysis transition against the competing risks of bleeding and mortality.”

The team noted that several studies are ongoing to establish whether the risk of bleeding exceeds the risk of stroke in patients who develop atrial fibrillation after transition to dialysis. 

Read more of Renal & Urology News’ coverage of NKF’s 2019 Spring Clinical Meetings by visiting the conference page.

Reference

Marroquin M, Sy J, Potukuchi P, Agarwal M, et al. Risk of bleeding vs stroke in ESRD patients with atrial fibrillation. Poster presented at the National Kidney Foundation’s 2019 Spring Clinical Meetings in Boston, May 8-12, 2019. Poster 202.