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Presence of CKD ups risk for stroke, systemic thromboembolism in AF patients
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Results of a new study reveal that chronic kidney disease is associated with increased risk for stroke or systemic thromboembolism and bleeding among patients with atrial fibrillation.
Using Danish national registries, researchers identified all patients discharged from the hospital with a diagnosis of nonvalvular AF from 1997 to 2008. The analysis included 132,372 patients; of those, 2.7% had non–end-stage chronic kidney disease (CKD) and 0.7% required renal-replacement therapy at the time of study inclusion.
Data from the large cohort study revealed that, compared with patients who did not have renal disease, those with non–end-stage CKD were at heightened risk for stroke or systemic thromboembolism (HR=1.49; 95% CI, 1.38-1.59). The same increased risk was also observed for patients requiring renal-replacement therapy (HR=1.83; 95% CI, 1.57-2.14). The presence of CKD was also associated with increased risk for MI and death from any cause vs. patients with no renal disease.
Warfarin use significantly decreased risk for stroke or systemic thromboembolism for patients with and without CKD (HR=0.76; 95% CI, 0.64-0.91), as did warfarin plus aspirin (HR=0.74; 95% CI, 0.56-0.98), according to the study abstract. Aspirin, however, was associated with an increased risk for stroke or systemic thromboembolism among patients with any renal disease vs. those without renal disease (HR=1.17; 95% CI, 1.01-1.35).
Risk for bleeding was increased among all patients with renal disease. Risk was further increased with use of warfarin (HR=1.33; 95% CI, 1.16-1.53), aspirin (HR=1.17; 95% CI, 1.02-1.34) and warfarin plus aspirin (HR=1.61; 95% CI, 1.32-1.96). Bleeding risk was also increased with use of higher-dose loop diuretics in patients with non–end-stage CKD. Patients with chronic glomerulonephritis had the highest bleeding risk, and patients with chronic tubulointerstitial nephropathy had the lowest bleeding risk.
“The net clinical effect of warfarin treatment requires careful assessment in patients with CKD, and the data do not provide clear guidance regarding indications for anticoagulant therapy in patients with both AF and CKD. … Ideally, the role of warfarin (or of other, newer anticoagulant agents) in patients with AF who have CKD should be evaluated in a clinical trial,” the researchers wrote.
Disclosure: Dr. Olesen reports receiving travel support from AstraZeneca and Boehringer Ingelheim. See the full study for a list of disclosures.
Perspective
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Douglas P. Zipes, MD
It is clear that CKD is an important risk factor for patients with CVD, and has been shown to adversely affect outcome in patients with a host of clinical problems, including AF, HF, ICD recipients and, in the present study, risk for stroke or systemic thromboembolism. Certainly the interactions are complex and may not be the same for each disease state, but it is important for cardiologists to pay more attention to the presence of CKD, both as a risk factor and as a therapeutic endpoint.
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