August 1, 2013
View Full PaperImpact of restarting warfarin therapy in renal disease anticoagulated patients with gastrointestinal hemorrhage
Key Result
Resuming warfarin after a gastrointestinal bleed in CKD patients decreased stroke/TIA rates (p<0.0001), while in ESRD patients it increased recurrent bleeding but decreased mortality and stroke/TIA.
Study Design
Type
Cohort (n=11,513)
Multicenter
Yes
Structured PICO
Does resuming warfarin therapy reduce mortality and stroke/TIA, or increase recurrent GIB, in atrial fibrillation patients with renal disease after a gastrointestinal bleeding episode?
P
Population
11,513 patients with atrial fibrillation on warfarin, including 159 with chronic kidney disease and 96 with end-stage renal disease who developed an index gastrointestinal bleed, followed for 90 days.
E
Exposure
Resumption of warfarin therapy after an episode of gastrointestinal bleeding
C
Comparator
Discontinuation (not resuming) of warfarin therapy
O
Outcome
90-day recurrent gastrointestinal bleeding (GIB), mortality, and stroke/transient ischemic attack (TIA)hard clinical
Resuming warfarin after gastrointestinal bleeding in AF patients with renal disease reduces stroke and mortality, but increases the risk of recurrent bleeding in those with end-stage renal disease.
Main Result
p-value: p=<0.0001
Abstract
BACKGROUND: Atrial fibrillation (AF) is emerging as a major health problem. The prevalence is as high as 32% in patients with renal disease. Gastrointestinal bleeding (GIB) is a frequent complication. OBJECTIVE: To investigate the hazards of resumption or discontinuation of anticoagulation in renal disease patients after an episode of GIB. DESIGN, SETTINGS, PARTICIPANTS AND MEASUREMENTS: This is a multicenter retrospective cohort of patients with AF on warfarin that developed an episode of GIB. Chronic kidney disease (CKD) was defined by eGFR ≤60 mL/min and end stage renal disease (ESRD) was defined by being on hemodialysis for >3 months. Outcomes were 90-day recurrent gastrointestinal bleeding (GIB), mortality, and stroke/transient ischemic attack (TIA). RESULTS: Out of 11,513 AF patients, index GIB occurred in 96 ESRD and 159 CKD patients. Outcomes of CKD patients did not differ when compared with patients with normal kidney function. CKD patients who resumed warfarin had decreased stroke/TIA rates (p 0.05). ESRD patients also did not have significant differences in outcomes when compared to patients with normal kidney function restarted on warfarin. However, there was an increase in recurrent GIB and decrease in mortality as well as stroke/TIA when patients with ESRD that restarted warfarin were compared with ESRD patients who did not restart warfarin. CONCLUSION: Study suggests resuming warfarin after an episode of GIB in CKD patients but recommends considering the increased risk of recurrent GIB in ESRD patients.