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Treatment of atrial fibrillation with warfarin among older adults with end stage renal disease

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Abstract

Background

There is increasing evidence questioning the use of warfarin for atrial fibrillation (AF) among older adults with end stage renal disease (ESRD). We assessed the patterns and determinants of warfarin utilization among these patients in the US.

Methods

We assembled a cohort of older adults (age ≥65) undergoing dialysis with incident AF from July 2007 to November 2011 from the US Renal Data System (USRDS). We used descriptive statistics to characterize warfarin utilization within 30 days of AF discharge, and logistic regression to quantify patient characteristics associated with warfarin initiation.

Results

Among 5730 older adults undergoing dialysis with incident AF, 15.5% initiated warfarin. Among 2906 patients with high risk of bleeding, 12.7% initiated warfarin; whereas 14.9% initiated warfarin among 4824 patients with high risk of stroke. After adjustment for patient characteristics, warfarin initiation was lower among patients who were older [odds ratio (OR) = 0.74 per 10-year increase, 95% confidence interval (CI) 0.66–0.83] and those with a history of diabetes (OR = 0.75, 95% CI 0.63–0.90), myocardial infarction (OR = 0.64, 95% CI 0.50–0.80), or bleeding (OR = 0.63, 95% CI 0.50–0.80). There was no association between sex, race, or dialysis modality and warfarin initiation. Among patients who initiated warfarin, 46.8% discontinued warfarin use after a median treatment length of 8.6 months.

Conclusion

Despite the unclear benefit and increased bleeding risk of warfarin treatment in patients with ESRD, 1 in 8 older adults undergoing dialysis with incident AF in the US who had high risk of bleeding used warfarin. Changes to warfarin therapy due to discontinuation were common after initiation.

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Abbreviations

ESRD:

End stage renal disease

AF:

Atrial fibrillation

CI:

Confidence interval

OR:

Odds ratio

IQR:

Interquartile range

INR:

International normalized ratio

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Acknowledgements

The data reported here have been supplied by the United States Renal Data System (USRDS). The interpretation and reporting of these data are the responsibility of the author(s) and in no way should be seen as an official policy or interpretation of the U.S. government. This research was supported by the National Heart, Lung, and Blood Institute (T32HL007024) pre-doctoral training grant and the doctoral dissertation fund provided by the Johns Hopkins Bloomberg School of Public Health Department of Epidemiology. Jodi B. Segal was supported by the National Institute on Aging (K24AG049036). Mara McAdams-DeMarco was supported by the American Society of Nephrology Carl W. Gottschalk Research Scholar Grant and Johns Hopkins University Claude D. Pepper Older Americans Independence Center, and the National Institute on Aging (P30AG021334 and K01AG043501). Dorry Segev was supported by the National Institute for Diabetes and Digestive and Kidney Disorders (K24DK101828). The funding sources had no role in the design and conduct of the study, analysis, or interpretation of the data; and preparation or final approval of the manuscript prior to publication.

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Authors and Affiliations

  1. Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615, N. Wolfe St, W6033, Baltimore, MD, 21205, USA

    Jingwen Tan, Jodi B. Segal, G. Caleb Alexander & Mara McAdams-DeMarco

  2. Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA

    Jingwen Tan, Sunjae Bae, Dorry L. Segev & Mara McAdams-DeMarco

  3. Center for Drug Safety and Effectiveness,, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

    Jodi B. Segal, G. Caleb Alexander & Mara McAdams-DeMarco

  4. Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA

    Jodi B. Segal & G. Caleb Alexander

  5. Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

    Jodi B. Segal & Junya Zhu

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  1. Jingwen Tan
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Correspondence to Mara McAdams-DeMarco.

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Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Conflict of interest

G. Caleb Alexander is Chair of the FDA’s Peripheral and Central Nervous System Advisory Committee; serves as a paid consultant to PainNavigator, a mobile startup to improve patients’ pain management; serves as a paid consultant to IMS Health; and serves on an IMS Health scientific advisory board. This arrangement has been reviewed and approved by Johns Hopkins University in accordance with its conflict of interest policies.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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For this type of retrospective study using anonymous registry data, formal consent is not required.

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Tan, J., Bae, S., Segal, J.B. et al. Treatment of atrial fibrillation with warfarin among older adults with end stage renal disease. J Nephrol 30, 831–839 (2017). https://doi.org/10.1007/s40620-016-0374-6

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  • DOI: https://doi.org/10.1007/s40620-016-0374-6

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