Warfarin in Atrial Fibrillation Patients with Moderate Chronic Kidney Disease

• Published in: Clinical journal of the American Society of Nephrology 2011-11, Vol.6 (11), p.2599-2604
• Main Authors: Hart, Robert G, Pearce, Lesly A, Asinger, Richard W, Herzog, Charles A
• Format: Article
• Language: English
• Subjects: Aged; Anticoagulants - administration & dosage; Anticoagulants - adverse effects; Aspirin - administration & dosage; Atrial Fibrillation - blood; Atrial Fibrillation - complications; Atrial Fibrillation - drug therapy; Blood Coagulation - drug effects; Canada; Chi-Square Distribution; Chronic Disease; Drug Therapy, Combination; Female; Hemorrhage - chemically induced; Humans; International Normalized Ratio; Kaplan-Meier Estimate; Kidney Diseases - complications; Kidney Diseases - diagnosis; Male; Original; Platelet Aggregation Inhibitors - administration & dosage; Proportional Hazards Models; Risk Assessment; Risk Factors; Severity of Illness Index; Stroke - blood; Stroke - etiology; Stroke - prevention & control; Time Factors; Treatment Outcome; United States; Warfarin - administration & dosage; Warfarin - adverse effects
• ISSN: 1555-9041; 1555-905X
• DOI: 10.2215/CJN.02400311

The efficacy of adjusted-dose warfarin for prevention of stroke in atrial fibrillation patients with stage 3 chronic kidney disease (CKD) is unknown. Patients with stage 3 CKD participating in the Stroke Prevention in Atrial Fibrillation 3 trials were assessed to determine the effect of warfarin anticoagulation on stroke and major hemorrhage, and whether CKD status independently contributed to stroke risk. High-risk participants (n = 1044) in the randomized trial were assigned to adjusted-dose warfarin (target international normalized ratio 2 to 3) versus aspirin (325 mg) plus fixed, low-dose warfarin (subsequently shown to be equivalent to aspirin alone). Low-risk participants (n = 892) all received 325 mg aspirin daily. The primary outcome was ischemic stroke (96%) or systemic embolism (4%). Among the 1936 participants in the two trials, 42% (n = 805) had stage 3 CKD at entry. Considering the 1314 patients not assigned to adjusted-dose warfarin, the primary event rate was double among those with stage 3 CKD (hazard ratio 2.0, 95% CI 1.2, 3.3) versus those with a higher estimated GFR (eGFR). Among the 516 participants with stage 3 CKD included in the randomized trial, ischemic stroke/systemic embolism was reduced 76% (95% CI 42, 90; P < 0.001) by adjusted-dose warfarin compared with aspirin/low-dose warfarin; there was no difference in major hemorrhage (5 patients versus 6 patients, respectively). Among atrial fibrillation patients participating in the Stroke Prevention in Atrial Fibrillation III trials, stage 3 CKD was associated with higher rates of ischemic stroke/systemic embolism. Adjusted-dose warfarin markedly reduced ischemic stroke/systemic embolism in high-risk atrial fibrillation patients with stage 3 CKD.