Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taoyuan, , Taiwan.
Department of Medicine, Chang Gung University, Taoyuan, , Taiwan.
J Thromb Haemost. 2019 Jan;17(1):77-87. doi: 10.1111/jth.14347. Epub 2018 Dec 24.
Essentials Uncertainty remains about antiplatelets for vascular access patency in hemodialysis patients. 95 971 people under hemodialysis were followed in a claims database in Taiwan. Aspirin reduced vascular access failure rate and did not increase major bleeding rate. Clopidogrel, Aggrenox, and warfarin might increase major bleeding rate. SUMMARY: Background Dialysis adequacy is a major determinant of survival for patients with end-stage renal disease. Good vascular access is essential to achieve adequate dialysis. Objectives This study evaluated the impacts of different drugs on the vascular access failure rate of an arteriovenous fistula or an arteriovenous graft and the rate of major bleeding in hemodialysis patients. Patients and methods We studied patients with end-stage renal disease registered in the Taiwan National Health Insurance program from 1 January 1997 to 31 December 2012. A total of 95 971 patients were enrolled in our study. Vascular access dysfunction was defined as the need for thrombectomy or percutaneous angioplasty. Major bleeding was defined as emergency department visits or hospitalization with a primary diagnosis of gastrointestinal bleeding or intracerebral hemorrhage. The adjusted odds ratios between person-quarters with or without antiplatelet or oral anticoagulant use were calculated using a generalized estimating equation. Results The odds ratio of vascular access failure was 0.21 (0.11-0.39) for aspirin, 0.76 (0.74-0.79) for clopidogrel, 0.67 (0.59-0.77) for dipyridamole, 0.67 (0.53-0.86) for Aggrenox and 0.96 (0.90-1.03) for warfarin. The highest odds ratio for intracerebral hemorrhage was 5.33 (1.25-22.72) in younger patients using Aggrenox. The highest odds ratio for gastrointestinal bleeding was 1.34 (1.10-1.64) for clopidogrel. Conclusion Antiplatelet agents, but not warfarin, might reduce the vascular access thrombosis rate. The gastrointestinal bleeding rate was increased in the group using clopidogrel. Aggrenox should be used with caution in young individuals because it might increase the rate of intracerebral hemorrhage.
在血液透析患者的血管通路通畅性方面，抗血小板药物的效果仍存在不确定性。在台湾的一个理赔数据库中，对 95971 名血液透析患者进行了随访。阿司匹林降低了血管通路失败率，且未增加大出血发生率。氯吡格雷、Aggrenox 和华法林可能会增加大出血的发生率。
透析充分性是终末期肾病患者生存的主要决定因素。良好的血管通路对于实现充分透析至关重要。
本研究评估了不同药物对动静脉瘘或动静脉移植物血管通路失败率以及血液透析患者大出血发生率的影响。
我们研究了参加台湾全民健康保险计划的 1997 年 1 月 1 日至 2012 年 12 月 31 日期间登记的终末期肾病患者。共有 95971 名患者纳入本研究。血管通路功能障碍定义为需要血栓切除术或经皮血管成形术。大出血定义为因胃肠道出血或脑出血而需到急诊就诊或住院治疗。使用广义估计方程计算抗血小板药物或口服抗凝剂使用与未使用的个体季度之间的调整比值比。
阿司匹林的血管通路失败比值比为 0.21（0.11-0.39），氯吡格雷为 0.76（0.74-0.79），双嘧达莫为 0.67（0.59-0.77），Aggrenox 为 0.67（0.53-0.86），华法林为 0.96（0.90-1.03）。使用 Aggrenox 的年轻患者颅内出血的比值比最高，为 5.33（1.25-22.72）。氯吡格雷组胃肠道出血的比值比最高，为 1.34（1.10-1.64）。
抗血小板药物而非华法林可能会降低血管通路血栓形成率。氯吡格雷组的胃肠道出血发生率增加。由于 Aggrenox 可能会增加颅内出血的发生率，因此应谨慎用于年轻患者。
