Multinational Real-World Practice Patterns in the Use of Antithrombotic Therapy Among Patients on Hemodialysis and Peritoneal Dialysis

Abstract

Rationale & Objective

Patients with kidney failure requiring maintenance dialysis have a high risk of cardiovascular events warranting antithrombotic therapies, including oral anticoagulant (OAC) or antiplatelet therapy (APT). However, chronic use of antithrombotic therapy can increase the bleeding risk in patients receiving dialysis. However, little is known about medication use patterns and risk of bleeding events in real-world clinical practice.

Study Design

Retrospective analysis of data from 2 prospective cohort studies.

Setting & Participants

We included 27,612 patients from the Dialysis Outcomes and Practice Patterns Study (DOPPS) and 5,289 patients from the Peritoneal DOPPS (PDOPPS), international cohorts of hemodialysis (HD) and peritoneal dialysis (PD) patients.

Exposures

Patient demographics and comorbid conditions; OAC and APT use.

Outcomes

OAC and APT use; a bleeding composite outcome including a hospitalization or death because of a major bleeding event.

Analytical Approach

Descriptive analyses to explore OAC and APT utilization and crude rates of the bleeding composite outcome and Kaplan–Meier analyses to estimate medication discontinuation.

Results

Baseline OAC and APT use was 9% and 10% in HD patients and 4% and 7% in PD patients, respectively. Patients prescribed antithrombotic drugs were older and more likely to have a history of cardiovascular disease. After 36 months, the Kaplan–Meier estimated proportions of baseline users who remained on therapy were 57% for OAC and 53% for APT. The composite bleeding rates per 100 patient-years among patients with baseline OAC use versus baseline APT use versus neither were 8.6, 5.6, and 4.1 in HD patients and 12.0, 6.1, and 3.9 in PD patients, respectively.

Limitations

Potential for event misclassification; no over-the-counter medication data; rates unadjusted.

Conclusions

Antithrombotic drugs are infrequently prescribed and often discontinued in patients receiving HD or PD. With major bleeding event rates high among antithrombotic users, new strategies are needed to optimize the risks and benefits of antithrombotic agents in the dialysis setting.

Plain-language Summary

Patients on dialysis face a difficult balance: they are at high risk for blood clots but also prone to serious bleeding. We examined real-world data from over 30,000 patients across multiple countries to understand how often blood thinners are used and what outcomes follow. We found that these medications are prescribed infrequently and often discontinued. Importantly, patients who received them experienced more major bleeding events. These findings highlight the urgent need for safer, more tailored approaches to managing clotting risks in dialysis care.