MO017ANTITHROMBOTIC THERAPIES AND CLINICAL OUTCOME OF ATRIAL FIBRILLATION IN ADULT HD-PATIENTS: LARGE LONG-TERM COHORT STUDY ON GERMAN NETWORK DATA
Authors: Brensing Karl August , Ochsmann Anna , Omran Heyder , Lonnemann Gerhard , Reichel Helmut , Duttlinger Johannes 
Published: June 2020

Abstract

Background and Aims
ESRD (end stage renal disease) patients on hemodialysis (HD) with persistent atrial fibrillation (AF) are at high risk for cardio-vascular events, severe bleeding and rapid vascular/valvular calcification. In such patients standard vitamin-K based oral anticoagulation (VK-OAC) is debated, since prospective OAC studies are missing and smaller short-term register data showed conflicting results. Our study evaluated risk-factors, use of anticoagulants and clinical long-term outcome in a large representative German HD-cohort.

Method
After informed consent, we analysed pseudonymized benchmarking data (2013-2018) of 16226 adult chronic HD patients treated in a German outpatient dialysis network (Verband Deutsche Nierenzentren, DN) based on quarterly electronically transmitted data. Diagnoses were coded by “International Classification of Diseases (ICD)” and drugs via “Anatomical Therapeutical Chemical (ATC)” codes.

Results
At baseline in 2013, 2812 (17%) HD-patients had AF as coded diagnosis. AF-prevalence increased significantly (p&lt;0.001) with age (&lt; 65 yrs: 7%; 65-&lt;75 yrs: 22% &gt;75 yrs: 34%) without gender differences. Baseline CHA2DS2-Vasc (4.0/1.5) and HAS-Bled (3.2/0.9) risk scores indicated high risk for embolism and bleeding. Median observation time was 2.1 yrs (Range: 0–6 yrs.). Apart from dialysis-related heparin-supply four main approaches were applied: No active therapy, standard VK-OAC+/- aspirin/clopidogrel (VK-OAC+/-Asp/Clop), heparin-based therapy (Heparin+/-Asp/Clop) or only anti-thrombocyte drugs (Asp/Clop).
Baseline risk scores were not related to any adverse events. Outcome data are shown in the Table: event rates were low (8.8%) and comparable for all anticoagulant therapies, especially for cerebral adverse events (3.8%, range 3.3-4.5%). Patients on any anti-thrombotic therapy had similar outcome rates as patients without anticoagulant therapy. The latter had fewer overall bleeding events (3.8% vs. 5.0%; NS).
Finally, overall actual 6-yr mortality rates were high (55.8%; median survival 4.4 yrs) and significantly (p&lt;0.001) lower for patients without anti-coagulant therapy (48.9%; median survival 6.0 yrs) than for patients on anti-coagulant therapy (59.5%; median survival 4.0 yrs) with highest mortality on VK-OAC based therapy (60.3%; p&lt;0.001).

Conclusion
De-novo cerebral event-rates were rather low (&lt;0.8%/yr) and similar for all anti-thrombotic therapies and even for patients with no active therapy, suggesting major beneficial impact of regular dialysis-related heparin-supply. Since actual 6-yr mortality was high and survival was significantly better in patients without anticoagulants than for VK-OAC or other active therapy, we need prospective studies comparing anticoagulants even with no drugs and/or new interventional approachs (i.e. left atrial appendage closure) to provide valid future guidelines.