Stroke prevention is one of the primary goals in end-stage renal disease (ESRD), also known as end-stage kidney disease (ESKD). In black, Hispanic, and Asian, or non-white, patients, there is an associated higher risk of stroke, which researchers believe may be due to atrial fibrillation and a lower likelihood of anticoagulant use. A retrospective cohort study published in the Journal of the American Society of Nephrology analyzed ESRD hemodialysis patients with atrial fibrillation to gain insight into the aforementioned stroke risk disparity.*

Background information

ESRD is the final stage of chronic kidney disease (CKD), which means the kidneys are failing and can no longer support the body’s needs without intervention in the form of dialysis or a kidney transplant. Hemodialysis is one of two types of dialysis, which is a procedure that cleans the blood to remove waste products, including creatinine, extra fluid, potassium, and urea, and can be done as an inpatient or outpatient treatment.

Atrial fibrillation (AF or AFib) is an irregular heartbeat (arrhythmia)—a condition that affects at least 2.7 million Americans. AF can cause blood clots, heart failure, a stroke, and other heart complications.

For patients with both ESRD and AF, stroke prevention is a key objective in treatment. This is typically achieved through the prescription of warfarin or another similar anticoagulant medication, otherwise known as “blood thinners” to prevent blood clots from forming.

Research and investigation details

With data from the United States Renal Data System (USRDS), researchers studied 56,587 ESRD hemodialysis patients, who started treatment between 2006 and 2013, and also had been diagnosed with atrial fibrillation and were receiving Medicare Part A, B, and/or D. Of those patients, 3% were Asian, 19% were black, 8% were Hispanic, and 69% were white. All patients were followed for a year for all-cause stroke and other related outcomes, such as with prescriptions and any related cardiovascular procedures.

Results and conclusions

The study found that, in comparison with white patients, “black, Hispanic, or Asian patients were more likely to experience stroke (13%, 15%, and 16%, respectively) but less likely to fill a warfarin prescription (10%, 17%, and 28%, respectively). Warfarin prescription was associated with decreased stroke rates. Analyses suggested that equalizing the warfarin distribution to that in the white population would prevent 7%, 10%, and 12% of excess strokes among black, Hispanic, and Asian patients, respectively.”

Moreover, the researchers concluded that further investigation is necessary to identify and address any and all potential barriers for anticoagulation medication in minority hemodialysis populations with atrial fibrillation in order to reduce the associated disproportionate stroke risk.

Added insight can be found on Healio under Nephrology News and Issues in an article by Paul L. Kimmel, “Racial disparities found in stroke prevention for kidney failure, atrial fibrillation patients.”

*Waddy, S., Solomon, A., Becerra, A., Ward, J., et al. (2020, Mar.). “Racial/Ethnic Disparities in Atrial Fibrillation Treatment and Outcomes among Dialysis Patients in the United States.” Journal of the American Society of Nephrology.