Key result
In dialysis patients with atrial fibrillation, warfarin use was not associated with all-cause mortality (HR 0.99; 95% CI 0.89-1.10) but significantly increased major bleeding (HR 1.35).
Why the study?
Does warfarin therapy reduce mortality or stroke/thromboembolism in dialysis patients with atrial fibrillation?
Meta-Analysis (n=37,349)
Does warfarin therapy reduce mortality or stroke/thromboembolism in dialysis patients with atrial fibrillation?
Hazard Ratio: 0.99 (95% CI 0.89–1.1)
p-value: p=0.825
In dialysis patients with atrial fibrillation, warfarin therapy does not reduce mortality or stroke risk but significantly increases the risk of major bleeding.
Warfarin offers no stroke or mortality benefit but raises major bleeding risk in dialysis AF; leaves open optimal anticoagulation strategies pending RCTs.
OBJECTIVE: To systematically review and meta-analyse the risk-benefit ratio of warfarin users compared with non-warfarin users in patients with atrial fibrillation (AF), who are undergoing dialysis. METHODS: We searched PubMed/MEDLINE, EMBASE, SCOPUS, Web of Science, Cochrane Library, grey literature, conference proceedings, trial registrations and also did handsearch. Cohort studies without language restrictions were included. Two investigators independently conducted a full abstraction of data, risk of bias and graded evidence. Effect estimates were pooled using random-effect models. MAIN OUTCOME MEASURE: All-cause mortality, total stroke/thromboembolism and bleeding complications. RESULTS: 14 studies included 37 349 dialysis patients with AF, of whom 12 529 (33.5%) were warfarin users. For all-cause mortality: adjusted HR=0.99 (95% CI 0.89 to 1.10; p=0.825), unadjusted risk ratio (RR)=1.00 (95% CI 0.96 to 1.04; p=0.847). For stroke/thromboembolism: adjusted HR=1.06 (95% CI 0.82 to 1.36; p=0.676), unadjusted incidence rate ratio (IRR)=1.23 (95% CI 0.94 to 1.61; p=0.133). For ischaemic stroke/transient ischaemic attack, adjusted HR=0.91 (95% CI 0.57 to 1.45; p=0.698), unadjusted IRR=1.16 (95% CI 0.84 to 1.62; p=0.370). For haemorrhagic stroke, adjusted HR=1.60 (95% CI 0.91 to 2.81; p=0.100), unadjusted IRR=1.48 (95% CI 0.92 to 2.36; p=0.102). Major bleeding was increased among warfarin users; adjusted HR=1.35 (95% CI 1.11 to 1.64; p=0.003) and unadjusted IRR=1.22 (95% CI 1.07 to 1.40; p=0.003). CONCLUSIONS: Among dialysis patients with AF, warfarin therapy was not associated with mortality and stroke/thromboembolism, but significantly increased the risk of major bleeding. More rigorous studies are essential to demonstrate the effect of warfarin for stroke prophylaxis in dialysis patients with AF.
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Nochaiwong et al. (2016) conducted a meta-analysis in Atrial fibrillation in patients undergoing dialysis (n=37,349). Warfarin vs. Non-warfarin users was evaluated on All-cause mortality (HR 0.99, 95% CI 0.89 to 1.10, p=0.825). In dialysis patients with atrial fibrillation, warfarin use was not associated with all-cause mortality (HR 0.99; 95% CI 0.89-1.10) but significantly increased major bleeding (HR 1.35).
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