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Kidney Week

Abstract: FR-PO407

Natural History of Atrial Fibrillation in Patients with ESKD on Hemodialysis

Session Information

Category: Dialysis

  • 701 Dialysis: Hemodialysis and Frequent Dialysis

Authors

  • Makar, Melissa S., Indiana University School of Medicine, Indianapolis, Indiana, United States
  • Wilson, Lauren E., Duke University School of Medicine, Durham, North Carolina, United States
  • Svetkey, Laura P., Duke University School of Medicine, Durham, North Carolina, United States
  • Hammill, Bradley G., Duke University School of Medicine, Durham, North Carolina, United States
  • Pun, Patrick H., Duke University School of Medicine, Durham, North Carolina, United States
  • Skinner, Asheley, Duke University School of Medicine, Durham, North Carolina, United States
Background

Anticoagulation for nonvalvular atrial fibrillation (AF) is controversial in patients with end-stage kidney disease (ESKD) maintained on hemodialysis (HD). Reserving anticoagulation for periods of highest stroke risk and lowest bleeding risk may help maximize the benefits of anticoagulation while minimizing the risks. To identify any such periods, we examined the natural history of untreated AF among those with ESKD maintained on HD.

Methods

We reviewed Medicare claims for HD patients aged >65 years that developed AF from 2011 to 2013 that did not have prescription claims for warfarin or direct oral anticoagulants in the months prior and post the AF diagnosis. Incident AF was defined as no prior claim for atrial fibrillation for at least a year before the index AF claim. Examining the twelve months following the AF diagnosis, we calculated the instantaneous hazard rates of ischemic stroke, major bleeding, and all-cause mortality. Patients were censored at date of death, date of kidney transplantation, or end of follow-up.

Results

We included 14,803 HD patients who had incident AF claims from 2011 to 2013 but no anticoagulation prescription claims. Almost all (99.9%) had a CHADS2-VASC score of 2 or higher with 34% of all patients having a score of 7 or higher. The majority of patients did not have a stroke or major bleed in the year prior to the index AF date (61% and 64%, respectively). We found low rates of ischemic stroke (40 events per 1000 person years); intermediate rates of major bleeding (232 events per 1000 person years); and high rates of all-cause mortality (739 events per 1000 person years). Hazard function plots illustrated that both ischemic stroke and bleeding rates were high immediately after the AF diagnosis but that both rates declined and stabilized around 30 days post-AF diagnosis.

Conclusion

Our results suggest that the risk of major bleeding may be highest immediately after the diagnosis of AF and that major bleeding may occur more frequently in this time period than ischemic stroke. The risks for both ischemic stroke and major bleeding appear to then decline and stabilize over time. Further research is needed to determine if reserving anticoagulation until one month post-AF diagnosis helps maximize the benefits of anticoagulation while minimizing the risks.