Harel Ziv, Chertow Glenn M, Shah Prakesh S, Harel Shai, Dorian Paul, Yan Andrew T, Saposnik Gustavo, Sood Manish M, Molnar Amber O, Perl Jeffrey, Wald Rachel M, Silver Sam, Wald Ron
Division of Nephrology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada.
Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, USA.
Can J Cardiol. 2017 Jun;33(6):737-746. doi: 10.1016/j.cjca.2017.02.004. Epub 2017 Feb 20.
Patients with atrial fibrillation who receive dialysis are at a high risk of ischemic stroke. The role of warfarin in mitigating this risk in patients with atrial fibrillation who receive dialysis is uncertain. Our objective was to examine the safety and efficacy of warfarin in patients who have atrial fibrillation and receive dialysis.
We used MedLine, Embase, and the Cochrane Library to conduct a systematic review and meta-analysis of published and unpublished observational and interventional studies related to the use of warfarin in patients with atrial fibrillation who receive dialysis, and provided data on the risk of stroke and/or bleeding outcomes relative to placebo or no anticoagulation therapy. A random effects model was used to calculate pooled adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for these outcomes.
No randomized controlled trials met the criteria for inclusion. Fourteen observational studies (20,398 participants) were included in the analysis. The use of warfarin was not associated with ischemic stroke (14 studies; 20,398 participants; aHR, 0.77; 95% CI, 0.55-1.07), intracranial hemorrhage (hemorrhagic stroke; 4 studies; 15,726 participants; aHR, 1.93; 95% CI, 0.93-4.00), gastrointestinal bleeding (3 studies; 14,693 participants; aHR, 1.19; 95% CI, 0.8-1.76), or all-cause mortality (7 studies; 16,172 participants; aHR, 0.89; 95% CI, 0.72-1.11).
Observational studies suggest that warfarin was not associated with a clear benefit or harm among patients who have atrial fibrillation and receive dialysis. These estimates were limited by study heterogeneity including the inability to account for a number of important confounders such as the time in the therapeutic range. Because of the high prevalence of atrial fibrillation, stroke, and bleeding complications in this population, well designed clinical trials of warfarin and other anticoagulants are urgently needed.
接受透析的心房颤动患者发生缺血性卒中的风险很高。华法林在降低接受透析的心房颤动患者发生这种风险方面的作用尚不确定。我们的目的是研究华法林在患有心房颤动并接受透析的患者中的安全性和有效性。
我们使用医学文献数据库（MedLine）、荷兰医学文摘数据库（Embase）和考克兰图书馆，对已发表和未发表的关于华法林在接受透析的心房颤动患者中应用的观察性和干预性研究进行系统评价和荟萃分析，并提供相对于安慰剂或无抗凝治疗的卒中风险和/或出血结局的数据。采用随机效应模型计算这些结局的合并调整风险比（aHRs）和95%置信区间（CIs）。
没有随机对照试验符合纳入标准。分析纳入了14项观察性研究（20398名参与者）。使用华法林与缺血性卒中（14项研究；20398名参与者；aHR，0.77；95%CI，0.55 - 1.07）、颅内出血（出血性卒中；4项研究；15726名参与者；aHR，1.93；95%CI，0.93 - 4.00）、胃肠道出血（3项研究；14693名参与者；aHR，1.19；95%CI，0.8 - 1.76）或全因死亡率（7项研究；16172名参与者；aHR，0.89；95%CI，0.72 - 1.11）均无关。
观察性研究表明，在患有心房颤动并接受透析的患者中，华法林未显示出明显的益处或危害。这些估计受到研究异质性的限制，包括无法考虑一些重要的混杂因素，如处于治疗范围内的时间。由于该人群中心房颤动、卒中和出血并发症的高患病率，迫切需要设计良好的华法林和其他抗凝剂的临床试验。
