Lei Hong, Yu Li-Ting, Wang Wei-Ning, Zhang Shun-Guo
Department of Traditional Medicine Testing, Institute for Drug and Instrument Control of Beijing Military Area Command, Beijing, China.
Department of Clinical Pharmacy, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
Front Pharmacol. 2018 Nov 6;9:1218. doi: 10.3389/fphar.2018.01218. eCollection 2018.
Up to date, the efficacy and safety of warfarin treatment in atrial fibrillation patients receiving hemodialysis remain controversial. So we performed this meta-analysis to try to offer recommendations regarding warfarin management in this population. We searched Pubmed, Embase, and Cochrane library and reviewed relevant reference lists from 1980 to March 2018. Studies were included if they described the risks of mortality, stroke, and bleeding events with or without warfarin in atrial fibrillation patients receiving hemodialysis. Overall, the use of warfarin was not associated with mortality (OR = 0.95, 95%CI = 0.89-1.02), stroke (OR = 1.06, 95% CI = 0.87-1.30) and ischemic stroke (OR = 0.85, 95% CI = 0.68-1.05), but its use could increase the risks of hemorrhagic stroke (OR = 1.34, 95% CI = 1.13-1.59) and major bleeding (OR = 1.24, 95% CI = 1.14, 1.35). In subgroup analyses, when analyses were mainly restricted to atrial fibrillation patients who were undergoing hemodialysis and taking other anticoagulation agents, warfarin therapy didn't reduce the risks for mortality (OR = 0.98, 95% CI = 0.68-1.42) and ischemic stroke (OR = 1.03, 95% CI = 0.89-1.19), but significantly increased the risks of stroke (OR:1.14, 95% CI = 1.01-1.29) and bleeding events such as hemorrhagic stroke (OR = 1.42, 95% CI = 1.14-1.77) and major bleeding (OR = 1.24, 95% CI = 1.14-1.35). While in patients who didn't take other anticoagulation agents or aspirin, warfarin use was not associated with all-cause mortality (OR = 0.90, 95% CI = 0.78-1.04), or any stroke (OR = 1.00, 95% CI = 0.71-1.40). Its use was associated with significantly decreased risk of ischemic stroke (OR = 0.71, 95% CI = 0.60-0.85), but not associated with hemorrhagic stroke (OR = 1.45, 95% CI = 0.83-2.55). Besides, another subgroup analysis showed that warfarin therapy didn't exert a protective role in patients with normal serum lipid levels (OR = 1.04, 95% CI = 0.85-1.26), but seemed to decrease the risk of ischemic stroke in patients with hyperlipidemia (OR = 0.38, 95% CI = 0.11-1.29). Our results suggested that it was necessary to prescribe warfarin for the prevention of ischemic events in hemodialysis patients with atrial fibrillation, but if these patients were already prescribed with other anticoagulants for the treatment of other co-existing diseases, then warfarin was not recommended.
迄今为止，华法林治疗在接受血液透析的房颤患者中的疗效和安全性仍存在争议。因此，我们进行了这项荟萃分析，试图就该人群的华法林管理提供建议。我们检索了PubMed、Embase和Cochrane图书馆，并查阅了1980年至2018年3月的相关参考文献列表。纳入的研究需描述接受血液透析的房颤患者使用或未使用华法林时的死亡、中风和出血事件风险。总体而言，使用华法林与死亡率（OR = 0.95，95%CI = 0.89 - 1.02）、中风（OR = 1.06，95%CI = 0.87 - 1.30）和缺血性中风（OR = 0.85，95%CI = 0.68 - 1.05）无关，但其使用会增加出血性中风（OR = 1.34，95%CI = 1.13 - 1.59）和大出血（OR = 1.24，95%CI = 1.14，1.35）的风险。在亚组分析中，当分析主要限于正在接受血液透析且服用其他抗凝剂的房颤患者时，华法林治疗并未降低死亡率（OR = 0.98，95%CI = 0.68 - 1.42）和缺血性中风（OR = 1.03，95%CI = 0.89 - 1.19）的风险，但显著增加了中风（OR:1.14，95%CI = 1.01 - 1.29）和出血事件如出血性中风（OR = 1.42，95%CI = 1.14 - 1.77）及大出血（OR = 1.24，95%CI = 1.14 - 1.35）的风险。而在未服用其他抗凝剂或阿司匹林的患者中，使用华法林与全因死亡率（OR = 0.90，95%CI = 0.78 - 1.04）或任何中风（OR = 1.00，95%CI = 0.71 - 1.40）无关。其使用与缺血性中风风险显著降低相关（OR = 0.71，95%CI = 0.60 - 0.85），但与出血性中风无关（OR = 1.45，95%CI = 0.83 - 2.55）。此外，另一亚组分析显示，华法林治疗在血脂正常的患者中未发挥保护作用（OR = 1.04，95%CI = 0.85 - 1.26），但似乎可降低高脂血症患者缺血性中风的风险（OR = 0.38，95%CI = 0.11 - 1.29）。我们的结果表明，有必要为预防接受血液透析的房颤患者发生缺血性事件而开具华法林，但如果这些患者已因治疗其他并存疾病而开具了其他抗凝剂，则不建议使用华法林。
