Is low-dose aspirin (acetylsalicylic acid) contraindicated in patients with essential fibrosis and stage 2 Chronic Kidney Disease (CKD) with an estimated Glomerular Filtration Rate (eGFR) of 77?

Low-Dose Aspirin in Essential Fibrosis with Stage 2 CKD

Low-dose aspirin is not contraindicated in patients with essential fibrosis and stage 2 CKD (eGFR 77 ml/min/1.73m²), and can be safely used for secondary prevention of cardiovascular disease, but should be avoided for primary prevention due to increased bleeding risk without clear cardiovascular benefit.

Aspirin Use in CKD: Guidelines and Evidence

Secondary Prevention

• The 2024 KDIGO guidelines clearly recommend low-dose aspirin for secondary prevention in patients with CKD who have established cardiovascular disease 1
• This recommendation is supported by the American Heart Association, which states it is reasonable to continue aspirin indefinitely after renal transplantation in patients with known coronary artery disease 1

Primary Prevention

• For primary prevention, the evidence does not support routine use of aspirin in CKD patients:
  • A 2016 meta-analysis found no clear benefit of aspirin for primary prevention of cardiovascular events in CKD and showed increased risk of major bleeding events (RR 1.98,95% CI 1.11 to 3.52) 2
  • A 2014 study suggested potential harmful consequences related to cardiovascular disease development and renal progression with low-dose aspirin in CKD patients 3

Stage 2 CKD Considerations

• With an eGFR of 77 ml/min/1.73m², this patient has mild kidney dysfunction (Stage 2 CKD)
• At this level of kidney function, no dose adjustment of aspirin is required 4
• The risk of adverse effects is lower compared to more advanced CKD stages, but still warrants consideration

Bleeding Risk Assessment

Factors Increasing Bleeding Risk

• CKD is associated with platelet dysfunction that increases bleeding risk 4
• Aspirin, even at low doses, increases the relative risk of major gastrointestinal bleeding (relative risk 1.6) 1
• Enteric coating does not appear to reduce this risk 1

Monitoring Recommendations

• Regular monitoring for bleeding complications is recommended for CKD patients on aspirin therapy 4
• Consider gastroprotection with proton pump inhibitors for high-risk patients, such as those with a history of gastrointestinal bleeding 4

Recent Evidence on Aspirin in CKD

Interestingly, recent research presents conflicting evidence:

• A 2023 study from the TIPS-3 trial showed that in participants with eGFR <60 ml/min/1.73m², aspirin reduced cardiovascular events (HR 0.57; 95% CI 0.34-0.94) 5
• However, a 2018 randomized controlled trial (AASER Study) found that aspirin did not significantly reduce the primary composite endpoint of cardiovascular events in CKD patients, though it showed potential benefits for secondary endpoints 6

Decision Algorithm for Aspirin Use in CKD Stage 2

1. For secondary prevention (patients with established cardiovascular disease):

   • Use low-dose aspirin (75-100 mg daily)
   • Monitor for bleeding complications
   • Consider gastroprotection if additional risk factors for bleeding exist

2. For primary prevention (no established cardiovascular disease):

   • Generally avoid aspirin use
   • If very high cardiovascular risk exists, perform individual risk-benefit assessment
   • Consider alternative preventive strategies (statins, blood pressure control)

Conclusion

For a patient with essential fibrosis and stage 2 CKD (eGFR 77), low-dose aspirin:

• Is not contraindicated based on kidney function alone
• Is recommended if the patient has established cardiovascular disease
• Should be avoided for primary prevention due to increased bleeding risk without clear cardiovascular benefit
• Does not require dose adjustment at this level of kidney function