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Anticoagulant and Antiplatelet Usage Associates with Mortality among Hemodialysis Patients

Kevin E. Chan^*, J. Michael Lazarus^*, Ravi Thadhani and Raymond M. Hakim^*

^* Fresenius Medical Care NA, Waltham, Massachusetts and Nephrology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts

Correspondence: Dr. Kevin E. Chan, 920 Winter Street, Waltham, MA 02451. Phone: 781-699-3272; Fax: 781-482-6247; E-mail: kevin.chan{at}fmc-na.com

Received for publication August 4, 2008. Accepted for publication January 15, 2009.

Many prescribe anticoagulants and antiplatelet medications to prevent thromboembolic events and access thrombosis in dialysis patients despite limited evidence of their efficacy in this population. This retrospective cohort study examined whether use of warfarin, clopidogrel, and/or aspirin affected survival in 41,425 incident hemodialysis patients during 5 yr of follow-up. The prescription frequencies for warfarin, clopidogrel, and aspirin were 8.3, 10.0, and 30.4%, respectively, during the first 90 d of initiating chronic hemodialysis. Compared with the 24,740 patients receiving none of these medications, Cox proportional hazards analysis suggested that exposure to these medications was associated with increased risk for mortality (warfarin hazard ratio [HR] 1.27 [95% confidence interval (CI) 1.18 to 1.37]; clopidogrel HR 1.24 [95% CI 1.13 to 1.35]; and aspirin HR 1.06 [95% CI 1.01 to 1.11]). The increased mortality associated with warfarin or clopidogrel use remained in stratified analyses. A covariate- and propensity-adjusted time-varying analysis, which accounted for longitudinal changes in prescription, produced similar results. In addition, matching for treatment facility and attending physician revealed similar associations between prescription and mortality. We conclude that warfarin, aspirin, or clopidogrel prescription is associated with higher mortality among hemodialysis patients. Given the possibility of confounding by indication, randomized trials are needed to determine definitively the risk and benefit of these medications.

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Copyright © 2009 by the American Society of Nephrology. Online ISSN: 1533-3450 Print ISSN: 1046-6673