Discussion

Discussion
Anticoagulants in patients with advanced CKD

significantly increased the risk of hemorrhage

lower all-cause mortality

but no clear reduction in the risk of ischemic

stroke.

In nonend-stage kidney disease patients,
warfarin does not decreased significantly risk
of stroke or systemic thromboembolism
There was an increased risk of bleeding
Danish national registries, Olesen et al

CKD patients prescribed warfarin had lower

risks of death, readmission due to myocardial
infarction, or ischemic stroke across all eGFR
Warfarin was not associated with significant
bleeding : readmission d/t hemorrhagic stroke,
GI bleeding, bleeding with anemia
Carrero et al

In A.fib patients) Rate of ischemic stroke or systemic
thromboembolism
7.4 (No anti-coagulation Tx) > 7.2 (with anti-coagulation Tx)
Rates of all-cause mortality were lower in patients on
anticoagulation
The incidence of major bleeding was higher in
patients on anticoagulation
Banerjee et al

Nonend-stage CKD patients, warfarin

decreased risk of ischemic stroke /thromboembolism,
decreased risk of all-cause mortality
/ nonsignificant risk of major bleeding
A meta-analysis of 5 observational studies (41,767 patients)


Using outpatient serum Cr values to diagnose CKD

less misclassification & appropriate stratification of
patients into Kidney Disease Improving Global Outcomes
(KDIGO) CKD categories.

Anticoagulant assignment was not random

Using Propensity score matching (PSM)
to reduce baseline differences between those who
did and who did not receive anticoagulation


Focused only elderly patients (>66 y)

they are the fastest growing population & at the
highest risk for anticoagulant-related complications.

Using Competing Risk

to account for the high risk of death
in elderly patients with advanced CKD
and a time-varying analysis of anticoagulation use.

Lack of reduction in the risk of ischemic stroke with
anticoagulants in advanced CKD was contrary to a
recently published systematic review in CKD and
studies in the general population.

Time-varying analysis raised the possibility of an

increase in stroke risk on anticoagulation.

Why?


Population-level cohort study

more marginal patients who would have been
excluded from trials might have received anticoagulants

Include patients with all CHADS 2 -VASc scores

In the general population, lower scores patients might be
treated with antiplatelet agents only.
: the evidence base for these treatment did not include
& cant extrapolate to patients with advanced CKD.

Elderly patients character
Risk of side effects or intolerance to anticoagulants
: stop Tx , shorter than general population
Warfarin : cardio-embolic stroke
(m/c anticoagulant)
But, simultaneously, vascular calcification
: can lead stroke in watershed vascular territories or lacunar infarcts
Elderly patients had more higher burdens of vascular
calcification.

CKD Patients tend to have increased variability in

the international normalized ratio, with less time in the
therapeutic range