The following sections have been prepared to ensure that the state of the art and science related to CVD includes novel concepts, therapeutic strategies, and emerging areas of pathophysiological and practical importance to the care of dialysis patients.
The reader will notice that the format of this section is different, reflecting its different perspective: namely, the relative lack of evidence on which to base plausible guideline statements. The evidence that does exist, and is cited in this section, is either completely in nondialysis populations, or is purely associative information, with no intervention in any population yet tested. Thus, it would be a problem to include guideline statements or recommendations.
Nonetheless, this section describes the current status of knowledge with respect to risk factors and biomarkers, and represents an overview of key areas for future clinical trials. The reader is encouraged to review this section, and examine his or her current understanding and practice within the context of these highlights.
The literature review has been conducted using the same systematic strategy as for the previous guidelines in this document. The reviews presented here have been thoughtfully constructed so that clinicians can adopt different practices based on them. However, for reasons cited above, the ability to truly recommend or suggest changes in practice would be premature at this time.
There are no randomized controlled trials in dialysis patients that establish the safety and efficacy of aspirin for primary or secondary prevention of atherosclerotic events. However, since CKD patients are among the highest-risk groups for atherosclerotic events, it might be reasonable to use aspirin in dialysis patients without contraindications for aspirin therapy.
There are no data on use of aspirin in primary prevention of CVD in dialysis patients. In an observational study of 3,374 incident dialysis patients with and without CAD in the USRDS Dialysis Morbidity Mortality Study Wave II, patients on aspirin had 2.9-fold higher hazard of acute coronary syndrome in unadjusted analysis.734 However, this result was nonsignificant in multivariate analysis. Even though this study used Medicare data to track acute coronary syndromes, not all of the study patients were on Medicare.
In an analysis of the Cooperative Cardiovascular Project, dialysis patients who received aspirin following MI had 43% lower odds of dying within 30 days in a multivariate analysis.735 Another observational retrospective study found that the use of aspirin and beta-blockers following MI was associated with lower mortality in patients with CKD.61 Thus, there are reasonable data to support the use of aspirin following MI.
The major risk of aspirin therapy is gastrointestinal (GI) bleeding. A randomized controlled trial of aspirin plus clopidrogel versus placebo to prevent AV graft thrombosis was terminated early because of GI bleeding.66 However, a retrospective observational study of USRDS data did not find increased risk of GI bleeding with aspirin.736
Aspirin may be useful for primary prevention of atherosclerotic disease in dialysis patients, with careful monitoring for bleeding complications. Its use following MI is warranted, based on the available evidence. Further large, prospective, observational studies and randomized controlled trials are required.