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Stroke and Bleeding in Atrial Fibrillation With Chronic Kidney Disease
Study Questions:
What is the risk of stroke or systemic thromboembolism and bleeding associated with chronic kidney disease among patients with atrial fibrillation?
Methods:
Using Danish national registries, the investigators identified all patients discharged from the hospital with a diagnosis of nonvalvular atrial fibrillation between 1997 and 2008. The risk of stroke or systemic thromboembolism and bleeding associated with non–end-stage chronic kidney disease and with end-stage chronic kidney disease (i.e., disease requiring renal replacement therapy) was estimated with the use of time-dependent Cox regression analyses. In addition, the effects of treatment with warfarin, aspirin, or both in patients with chronic kidney disease were compared with the effects in patients with no renal disease. The risk of stroke or systemic thromboembolism associated with non–end-stage chronic kidney disease or disease requiring renal-replacement therapy was estimated by means of time-dependent Cox proportional-hazards models, with adjustment for changes in renal status or antithrombotic treatment during follow-up.
Results:
Of 132,372 patients included in the analysis, 3,587 (2.7%) had non–end-stage chronic kidney disease and 901 (0.7%) required renal-replacement therapy at the time of inclusion. As compared with patients who did not have renal disease, patients with non–end-stage chronic kidney disease had an increased risk of stroke or systemic thromboembolism (hazard ratio, 1.49; 95% confidence interval [CI], 1.38-1.59; p < 0.001), as did those requiring renal-replacement therapy (hazard ratio, 1.83; 95% CI, 1.57-2.14; p < 0.001); this risk was significantly decreased for both groups of patients with warfarin, but not with aspirin. The risk of bleeding was also increased among patients who had non–end-stage chronic kidney disease or required renal-replacement therapy, and was further increased with warfarin, aspirin, or both.
Conclusions:
The authors concluded that chronic kidney disease was associated with an increased risk of stroke or systemic thromboembolism and bleeding among patients with atrial fibrillation.
Perspective:
This study reports that among patients with atrial fibrillation, non–end-stage chronic kidney disease and disease requiring renal-replacement therapy were both associated with increased risks of stroke or systemic thromboembolism and bleeding. The effect of warfarin was similar among patients with atrial fibrillation and those without chronic kidney disease, reducing the risk of stroke or systemic thromboembolism and increasing the risk of bleeding. In contrast, aspirin was not associated with a reduced risk of stroke or systemic thromboembolism, but was associated with an increased risk of bleeding. The role and net clinical benefit of warfarin and newer anticoagulant agents in patients with atrial fibrillation who have chronic kidney disease should be evaluated in future prospective studies.
Keywords: Risk, Stroke, Follow-Up Studies, Warfarin, Thromboembolism, Registries, Renal Insufficiency, Proportional Hazards Models, Cardiology, Confidence Intervals, Hemorrhage, Renal Replacement Therapy
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