Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Comparative Study
. 2025 Sep 2;8(9):e2530990.
doi: 10.1001/jamanetworkopen.2025.30990.

Left Atrial Appendage Occlusion vs Anticoagulants in Dialysis With Atrial Fibrillation

Gaurav Dhar  1 , Milind A Phadnis  2 , Suzanne L Hunt  2 , Holly E Du  2 , Vincz Ong  3 , Ninad Khandekar  3 , Theresa I Shireman  4 , Donald Lynch  5 , Sandeep Randhawa  3 , Abhishek Deshmukh  6 , Srikanth Vallurapalli  3 , Nishank Jain  3
Affiliations
Comparative Study

Left Atrial Appendage Occlusion vs Anticoagulants in Dialysis With Atrial Fibrillation

Gaurav Dhar et al. JAMA Netw Open. .

Erratum in

  • Error in Byline.
    [No authors listed] [No authors listed] JAMA Netw Open. 2025 Oct 1;8(10):e2543432. doi: 10.1001/jamanetworkopen.2025.43432. JAMA Netw Open. 2025. PMID: 41114983 Free PMC article. No abstract available.

Abstract

Importance: Patients with kidney failure (KF) receiving long-term dialysis have increased incidence of atrial fibrillation (AF). Patients with KF and AF have increased risk of stroke, death, and bleeding compared with age-matched cohorts. In KF, the use of oral anticoagulants (OACs) increases hemorrhage risk, offsetting potential benefits and making left atrial appendage occlusion (LAAO) a potentially promising solution for risk reduction in AF.

Objectives: To compare the outcomes and safety of OACs and LAAO for risk reduction of AF in patients with KF.

Design, setting, and participants: This retrospective cohort study assessed patients with KF enrolled in the US Renal Data System registry between January 1, 2015, and December 31, 2018, who were diagnosed with AF after initiation of long-term dialysis. On average, patients met inclusion criteria for 22 months. Data analysis was completed in May 2024.

Exposure: Medicare claims were used to identify patients who received OACs and LAAO after AF diagnosis. A propensity-matched cohort was created based on the CHA2DS2-VASc score and year of treatment.

Main outcomes and measures: Death, nonfatal bleeds, and nonfatal strokes.

Results: The final cohort included 2344 patients with KF and a new AF diagnosis (median [IQR] age, 66.0 [57.0-73.0] years; 1341 [57.2%] male). Of these patients, 293 received LAAO and 2051 received OACs. A total of 2194 patients (93.6%) were receiving hemodialysis, with the remaining 150 (6.4%) receiving peritoneal dialysis. In the LAAO group, 79 deaths (27.0%) and 21 nonfatal strokes (7.2%) occurred, and 117 patients (39.9%) experienced 234 bleeding events. In the OAC group, 729 deaths (35.5%) and 163 strokes (8.0%) occurred, and 687 patients (33.5%) experienced 1114 bleeding events. After accounting for correlation between bleeds and death, the joint frailty model showed evidence of a treatment association of LAAO compared with OACs on recurrent bleeding events (hazard ratio [HR], 0.74; 95% CI, 0.56-0.98) and death (HR, 0.47; 95% CI, 0.30-0.72). There was a reduced risk of nonfatal stroke in the LAAO group (HR, 0.55; 95% CI, 0.32-0.94), but this finding was not significant after adjustment (HR, 1.18; 95% CI, 0.76-1.81).

Conclusions and relevance: In this cohort study, LAAO compared with OACs was associated with improved survival and reduced bleeding risk in patients with KF and AF. These findings suggest that these data should be considered in shared decision-making in consideration of LAAO for patients with KF and AF.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest Disclosures: Dr Dhar reported serving as a Boston Science Institute advisory board member outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Derivation of the Study Cohort
We obtained data from the US Renal Data System (USRDS) on unique patients who received long-term maintenance dialysis (hemodialysis or peritoneal dialysis). Patients in whom kidney transplant failed and who were returning for dialysis were also included. We excluded patients with end-stage kidney disease (ESKD) who did not survive for the first 6 months after starting dialysis or did not have a start date in the system. We further applied inclusion and exclusion criteria to identify patients with ESKD and an atrial fibrillation diagnosis (N = 42 857); 12 031 (28.3%) received only oral anticoagulants (OACs), 293 (0.7%) received left atrial appendage occlusion device (LAAO), and the remaining patients received neither treatment. Of the 293 patients who received LAAO, 175 (59.7%) received LAAO only, whereas the remaining 118 (40.3%) received LAAO after receiving OACs. ICD-10 indicates International Statistical Classification of Diseases and Related Health Problems, Tenth Revision.
Figure 2.
Figure 2.. Comparison of Time to Death Between Patients Only Taking Oral Anticoagulant (OACs) vs Those Using the Left Atrial Appendage Occlusion Device (LAAO) in a Univariable Survival Analysis Using Kaplan-Meier Curves
The figure shows a comparison of time to death between patients only taking OACs vs those using the LAAO in a univariable survival analysis using Kaplan-Meier curves. Statistical significance was determined using a log-rank test.
See this image and copyright information in PMC

References

    1. Benjamin EJ, Blaha MJ, Chiuve SE, et al. ; American Heart Association Statistics Committee and Stroke Statistics Subcommittee . Heart disease and stroke statistics-2017 update: a report from the American Heart Association. Circulation. 2017;135(10):e146-e603. doi: 10.1161/CIR.0000000000000485 - DOI - PMC - PubMed
    1. Joglar JA, Chung MK, Armbruster AL, et al. ; Peer Review Committee Members . 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024;149(1):e1-e156. doi: 10.1161/CIR.0000000000001193 - DOI - PMC - PubMed
    1. Genovesi S, Vincenti A, Rossi E, et al. Atrial fibrillation and morbidity and mortality in a cohort of long-term hemodialysis patients. Am J Kidney Dis. 2008;51(2):255-262. doi: 10.1053/j.ajkd.2007.10.034 - DOI - PubMed
    1. U.S. Renal Data System . 2020 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2020.
    1. Jain N, Reilly RF. Clinical pharmacology of oral anticoagulants in patients with kidney disease. Clin J Am Soc Nephrol. 2019;14(2):278-287. doi: 10.2215/CJN.02170218 - DOI - PMC - PubMed

Publication types

MeSH terms