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Warfarin Use Associates with Increased Risk for Stroke in Hemodialysis Patients with Atrial Fibrillation
Open accessAbstract
Use of warfarin, clopidogrel, or aspirin associates with mortality among patients with ESRD, but the risk-benefit ratio may depend on underlying comorbidities. Here, we investigated the association between these medications and new stroke, mortality, and hospitalization in a retrospective cohort analysis of 1671 incident hemodialysis patients with preexisting atrial fibrillation. We followed patient outcomes from the time of initiation of dialysis for an average of 1.6 yr. Compared with nonuse, warfarin use associated with a significantly increased risk for new stroke (hazard ratio 1.93; 95% confidence interval 1.29 to 2.90); clopidogrel or aspirin use did not associate with increased risk for new stroke. Analysis using international normalized ratio (INR) suggested a dose-response relationship between the degree of anticoagulation and new stroke in patients on warfarin (P = 0.02 for trend). Warfarin users who received no INR monitoring in the first 90 d of dialysis had the highest risk for stroke compared with nonusers (hazard ratio 2.79; 95% confidence interval 1.65 to 4.70). Warfarin use did not associate with statistically significant increases in all-cause mortality or hospitalization. In conclusion, warfarin use among patients with both ESRD and atrial fibrillation associates with an increased risk for stroke. The risk is greatest in warfarin users who do not receive in-facility INR monitoring.
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“Warfarin use was associated either with a neutral or increased risk of stroke in database analyses of patients on dialysis, [419][420][421] including a population-based analysis in Canada (adjusted HR for stroke 1.14; 95% CI 0.78-1.67,adjusted HR for bleeding 1.44; 95% CI 1.13-1.85).422”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [420]
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BackgroundUse of Oral Anticoagulation in the Management of Atrial Fibrillation in Patients with ESRD: Con
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“Some of the studies in the past have postulated that warfarin use in chronic hemodialysis accelerates vascular calcification and aortic stiffness by inhibiting the enzymeMatrix G1a and Gas-6 protein responsible for preventing calcification in vascular smooth muscle, thereby increasing the risk of ischemic stroke [13,2…”
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Warfarin Use and Increased Mortality in End-Stage Renal Disease
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“We report an overall stroke incidence markedly higher than the upper literatures [13–15], but in keeping with the US rates [16, 17] that a high incidence of stroke at 49/1,000 patient years in their HD and peritoneal dialysis population, which probably we applied a standard to diagnosed stroke by that having focal neu…”
ResultSakaan, S. A., Hudson, J. Q., Oliphant, C. S., Tolley, E. A., Cummings, C. D., Alabdan, N., & Self, T. H. (2014) · Pharmacotherapy The Journal of Human Pharmacology and Drug Therapy · doi:10.1002/phar.1445 · Cited by 22
“Atrial fibrillation 15 (31) 18 (41) 5 (19) 17 (18) 0.”
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“72) among warfarin versus nonwarfarin users (36).”
Metadata
- Authors
- Chan, K. E., Lazarus, J. M., Thadhani, R., & Hakim, R. M.
- Affiliations
- Fresenius Medical Care (United States) (US)
- Massachusetts General Hospital (US)
- Corresponding author
- Chan, Kevin E.
- Lazarus, J. Michael
- Hakim, Raymond M.
- Venue
- Journal of the American Society of Nephrology
- Published
- 2009-10
- Volume
- 20
- Issue
- 10
- Pages
- 2223-2233
- ISSN
- 1046-6673 (ISSN-L)
- PMC
- PMC2754104
- OpenAlex
- W2137138584
- Cited by
- 431
- References
- 86
- Citations by year
- 2026: 6 · 2025: 11 · 2024: 12 · 2023: 17 · 2022: 15 · 2021: 20 · 2020: 23 · 2019: 21 · 2018: 38 · 2017: 40 · 2016: 40 · 2015: 43 · 2014: 34 · 2013: 35 · 2012: 29
- FWCI
- 16.39
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Journal of the American Society of Nephrology (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Nephrology › Dialysis and Renal Disease Management
- Health Sciences › Medicine › Clinical Neurology › Acute Ischemic Stroke Management
- Keywords
- warfarin, stroke risk, hemodialysis, atrial fibrillation, end-stage renal disease, clopidogrel, aspirin, INR monitoring, anticoagulation, mortality, hospitalization
- MeSH terms
- Aged, Anticoagulants, Atrial Fibrillation, Female, Renal Dialysis, Hospitalization, Humans, Kidney Failure, Chronic, Male, Regression Analysis, Retrospective Studies, Risk, Warfarin, Cohort Studies, International Normalized Ratio, Stroke
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