Received March 20, 2009
Accepted on June 10, 2009

CLINICAL EPIDEMIOLOGY

Warfarin Use Associates with Increased Risk for Stroke in Hemodialysis Patients with Atrial Fibrillation

Kevin E. Chan ^*1, 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

¹ To whom correspondence should be addressed. E-mail: Kevin.chan{at}fmc-na.com.

	Abstract

Use of warfarin, clopidogrel, or aspirin associates with mortality among patients with ESRD, but the risk-benefit ratio may depend on underlying comorbidities. Here, we investigated the association between these medications and new stroke, mortality, and hospitalization in a retrospective cohort analysis of 1671 incident hemodialysis patients with preexisting atrial fibrillation. We followed patient outcomes from the time of initiation of dialysis for an average of 1.6 yr. Compared with nonuse, warfarin use associated with a significantly increased risk for new stroke (hazard ratio 1.93; 95% confidence interval 1.29 to 2.90); clopidogrel or aspirin use did not associate with increased risk for new stroke. Analysis using international normalized ratio (INR) suggested a dose-response relationship between the degree of anticoagulation and new stroke in patients on warfarin (P = 0.02 for trend). Warfarin users who received no INR monitoring in the first 90 d of dialysis had the highest risk for stroke compared with nonusers (hazard ratio 2.79; 95% confidence interval 1.65 to 4.70). Warfarin use did not associate with statistically significant increases in all-cause mortality or hospitalization. In conclusion, warfarin use among patients with both ESRD and atrial fibrillation associates with an increased risk for stroke. The risk is greatest in warfarin users who do not receive in-facility INR monitoring.