Japan: Study on Anticoagulation in ESKD Patients

A recent study suggests that international guideline recommendations for peri-procedural anticoagulation may not apply to end-stage kidney disease (ESKD) patients undergoing atrial fibrillation (AF) catheter ablation and calls for questioning anticoagulation's role in this population.

In a real-world setting, ESKD patients undergoing AF ablation are grossly underrated from the outlook of anticoagulation guideline recommendations, with 94% of patients having a subtherapeutic international normalized ratio (INR) at some point during the peri-procedural period.

The investigators wrote, "despite most patients with ESKD undergoing AF ablation showing undertreatment with warfarin, thromboembolic events are rare, but major bleeding events are common." The study was published in EP Europace on 09 March 2023.

According to the current peri-procedural anticoagulation guidelines, patients undergoing atrial fibrillation ablation should be under therapeutic anticoagulation throughout the peri-procedural period.

Chronic kidney disease and atrial fibrillation coexist, and many studies have revealed causal links between the two conditions. About 10–20% of patients with end-stage kidney disease are reported to have AF. The use of catheter ablation is growing in this population as many antiarrhythmic drugs undergo renal excretion or metabolism. It is widely accepted that patients undergoing AF ablation be put under therapeutic anticoagulation throughout the peri-procedural period, either with uninterrupted direct oral anticoagulants (DOACs) or continuous warfarin therapy with a target INR of 2.0–3.0.

The optimal anticoagulation regimen in end-stage kidney disease patients undergoing AF catheter ablation is unknown. Tasuku Yamamoto, Tokyo Medical and Dental University, Yushima, Tokyo, Japan, and colleagues sought to describe the real-world practice of peri-procedural anticoagulation management in patients with chronic kidney disease undergoing AF ablation.

The study included ESKD patients on haemodialysis undergoing catheter ablation for AF in Japan's 12 referral centres. 347 procedures were included in 307 patients (67 ±9 years, 40% female). The international normalized ratio was collected 1 and 3 months after ablation. Peri-procedural major haemorrhagic events and thromboembolic events were adjudicated.

Findings

• INR values were grossly subtherapeutic [1.58 before ablation, 1.54 at one month, and 1.22 at three months].
• Thirty-five patients (10%) suffered major complications, the majority of which was major bleeding (19 patients; 5.4%), including 11 cardiac tamponades (3.2%).
• Two peri-procedural deaths (0.6%) were related to bleeding events.
• A pre-procedural INR value of 2.0 or higher was the only independent predictor of major bleeding [odds ratio, 3.3].
• No cerebral or systemic thromboembolism occurred.

The investigators described the real-world practice of peri-procedural anticoagulation in ESKD patients undergoing AF ablation in 12 referral centres in Japan. In a vast majority of patients, INR values were grossly subtherapeutic. Nevertheless, no thromboembolic complications were seen, but haemorrhagic complications were common during the peri-procedural period.

Reference

Tasuku Yamamoto, Shinsuke Miyazaki, Yasuaki Tanaka, Toshikazu Kono, Tadanori Nakata, Akira Mizukami, Daisetsu Aoyama, Hirofumi Arai, Yuta Taomoto, Tomoki Horie, Rintaro Hojo, Shiho Kawamoto, Kento Yabe, Kikou Akiyoshi, Nobutaka Kato, Yuichi Ono, Atsushi Suzuki, Seiji Fukamizu, Yasutoshi Nagata, Yasuteru Yamauchi, Hiroshi Tada, Hitoshi Hachiya, Osamu Inaba, Atsushi Takahashi, Masahiko Goya, Tetsuo Sasano, Peri-procedural anticoagulation in patients with end-stage kidney disease undergoing atrial fibrillation ablation: results from the multicentre end-stage kidney disease–atrial fibrillation ablation registry, EP Europace, 2023;, euad056, https://doi.org/10.1093/europace/euad056