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Antiplatelet agents in hemodialysis
Massimiliano Migliori1, Vincenzo Cantaluppi2, Alessia Scatena3
1Nephrology and Dialysis, Azienda USL Nord Ovest Toscana, Versilia Hospital, Versilia, Italy. maxmigliori@yahoo.it.
Insights
Antiplatelet agents (AA) are used in chronic renal failure (CRF) patients for cardiovascular disease (CVD) prevention. While not proven for primary prevention, aspirin may benefit hemodialysis patients in secondary CVD prevention, balancing efficacy against bleeding risk.
Area of Science:
- Nephrology
- Cardiology
- Pharmacology
Background:
- Cardiovascular disease (CVD) is the leading cause of death in chronic renal failure (CRF) patients.
- CRF patients, especially those on hemodialysis (HD), have significantly higher risks of myocardial infarction (MI) and coronary artery disease (CAD) compared to the general population.
- Antiplatelet agents (AA) are crucial for managing various cardiovascular conditions but their role in CRF requires careful consideration.
Purpose of the Study:
- To evaluate the efficacy and safety of antiplatelet agents (AA) in patients with chronic renal failure (CRF).
- To determine the role of AA in primary and secondary prevention of cardiovascular events in hemodialysis (HD) patients.
- To assess the risk-benefit profile of aspirin and dual antiplatelet therapy in CRF patients.
Main Methods:
- Review of existing clinical data and studies on antiplatelet agent use in CRF and hemodialysis populations.
- Analysis of outcomes related to primary and secondary cardiovascular event prevention.
- Evaluation of hemorrhagic risk associated with antiplatelet therapy in this high-risk group.
Main Results:
- Current evidence does not support AA for primary prevention of cardiovascular mortality in hemodialysis patients.
- Studies suggest aspirin may reduce mortality in dialysis patients post-MI (secondary prevention).
- Dual AA therapy (aspirin plus clopidogrel) shows increased bleeding risk without significant cardiovascular benefit; data on new AA drugs are insufficient.
Conclusions:
- Aspirin may be considered for secondary CVD prevention in hemodialysis patients due to high atherosclerotic risk.
- Bleeding risk must be carefully evaluated in CRF patients, particularly before initiating dual AA treatment.
- Further research is needed to clarify the optimal use of antiplatelet agents in the CRF population.
Abstract:
Patients affected by cardiovascular disease (CVD) are treated with antiplatelet agents (AA) and/or anticoagulant drugs, which are fundamental in the management of stroke, coronary atherosclerotic disease, peripheral vascular disease and atrial fibrillation. CVD is the most important cause of death in chronic renal failure (CRF). Death rates from myocardial infarction (MI) and from all other cardiac causes exceed those for the general population. Incidence of MI in CRF is triple that in the general population. Moreover, mortality is seven- to eight-fold higher in patients requiring chronic hemodialysis compared to the general population, and approximately 40% of deaths in this population are attributable to coronary artery disease (CAD). For these reasons, AA are widely used in patients affected by CRF. Current data do not support a protective effect of antiplatelet administration in hemodialytic patients as primary prevention of cardiovascular mortality. Different results have been obtained concerning secondary prevention of CVD. The Cooperative Cardiovascular Project demonstrated that dialysis patients treated with aspirin following MI had a 43% lower mortality. Another study reported that the use of aspirin and beta-blockers following MI was associated with lower mortality in CRF patients. However, aspirin plus clopidogrel seems to increase the hemorrhagic risk without a significant reduction in cardiovascular mortality and there are insufficient data to support the use of new AA drugs in hemodialytic patients. In conclusion, since CRF patients are one of the groups at highest risk for atherosclerotic events, it could be reasonable to use aspirin in HD patients. However, the bleeding risk in HD patients needs to be strongly evaluated, especially before starting dual AA treatment.
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