The use of warfarin in patients with atrial fibrillation and end stage kidney disease.

Aim: To examine prescriber characteristics and reasoning for selection of stroke prevention therapy for dialysis patients with atrial fibrillation (AF). Background(s): Warfarin therapy in dialysis patients with AF remains controversial especially for primary stoke prevention. Method(s): Utilising scanned medical records, dialysis patients with AF at Monash Health were identified. Patient demographics, therapeutic agent for AF, prescriber characteristics and reasoning were then assessed. Result(s): Of 575 dialysis patients, 100 (17.4%) were identified as having AF. Of those, 31 patients received warfarin, 46 received antiplatelet therapy, 21 did not receive stroke prevention therapy and 2 received other forms of stroke prevention therapy (clexane non-dialysis days, apixaban). Of the 31 patients on warfarin, 15 were placed on warfarin for primary prevention, 13 for secondary prevention and 3 were unknown. The AF cohort was generally older compared to the cohort without AF (71.9 vs 61.2 years, p < 0.001). Demographically, patient subgroups on warfarin, antiplatelet agents and no stroke prevention therapy were similar. 16 of 31 patients were commenced on warfarin by cardiology, predominantly for primary stroke prevention (81%). Neurology commenced warfarin in 9 of 31 patients, in all instances for secondary stroke prevention (100%). 16 patients were previously on warfarin. Most cases of warfarin cessation were instigated by nephrology (63%) with major reasons including conflicting evidence regarding warfarin use in dialysis patients, bleeding complications, bleed risk greater than stroke risk, and dialysis commencement. Conclusion(s): Further research is required to provide an evidence-based approach to primary stroke prevention therapy in dialysis patients with AF. Presently, with limited evidence and differences in clinical practice between the various specialties, a multidisciplinary approach is necessary for the individualized management of AF in dialysis patients.