Stroke, Major Bleeding and Mortality Outcomes in Warfarin Users with Atrial Fibrillation and Chronic Kidney Disease: A Meta-analysis of Observational Studies.
Chest. 2015 Sep 17;
Authors: Dahal K, Kunwar S, Rijal J, Schulman P, Lee J
Abstract
Background: The use of warfarin in patients with atrial fibrillation (AF) and chronic kidney disease (CKD) can be problematic due to increased bleeding risk. We performed a systematic review and meta-analysis of observational studies that evaluated the use of warfarin in patients with AF and CKD to evaluate the risks of ischemic stroke/thromboembolism (IS/TE), major bleeding and mortality.
Methods: PUBMED, EMBASE, CINAHL, ProQuest and Google Scholar databases were electronically searched through 1/12/2015. Additionally, manual search was performed for relevant references. Random-effects model was used to estimate the pooled hazard ratio (HR) with 95% confidence interval (CI). CKD was divided into non-end-stage CKD and end-stage CKD (on renal replacement therapy) and separate analyses were performed.
Results: A total of 13 publications from 11 cohorts (6 retrospective and 5 prospective) including >48, 500 total patients with >11, 600 warfarin users were included in the meta-analysis. In patients with AF and non-end-stage CKD, warfarin resulted in a lower risk of ischemic stroke/thromboembolism (HR 0.70; 95% CI 0.54-0.89; P=0.004) and mortality (0.65; 0.59-0.72; P<0.00001) but had no effect on major bleeding (1.15; 0.88-1.49; P=0.31). In patients with AF and end-stage CKD, warfarin had no effect on the risks of stroke (1.12; 0.69-1.82; P=0.65) and mortality (0.96; 0.81-1.13; P=0.60) but increased the risks of major bleeding (1.30; 1.08-1.56; P=0.005).
Conclusions: Based on this meta-analysis, the use of warfarin for AF may have an unfavorable risk/benefit ratio in patients with end-stage CKD but not in those with non-end stage CKD.
PMID: 26378611 [PubMed - as supplied by publisher]