Can a patient with end‑stage renal disease be prescribed low‑dose (81 mg) aspirin?

Aspirin Use in End-Stage Renal Disease

Low-dose aspirin (75-100 mg daily) can be prescribed to ESRD patients for secondary prevention of cardiovascular disease, but should generally be avoided for primary prevention due to increased bleeding risk without proven cardiovascular benefit in this population. 1

Secondary Prevention: Recommended

For ESRD patients with established coronary artery disease, prior myocardial infarction, or prior stroke, aspirin should be continued indefinitely as the cardiovascular mortality reduction substantially outweighs bleeding risk. 2, 1

• In dialysis patients with acute myocardial infarction, aspirin reduced 30-day mortality by 36% (RR 0.64,95% CI 0.50-0.80), with similar benefit to non-ESRD patients. 3
• A retrospective study of dialysis patients with ischemic stroke found aspirin reduced the hazard ratio for death and stroke readmission to 0.671 (P < 0.001) without significantly increasing bleeding (HR 0.885, P = 0.291). 4
• The ACC/AHA guidelines recommend continuing aspirin after renal transplantation in patients with known CAD. 2

Dosing: Use 75-100 mg daily—no dose adjustment is required for renal function. 2, 1

Primary Prevention: Generally Not Recommended

Aspirin for primary prevention in ESRD should be avoided because no randomized controlled trials have demonstrated cardiovascular benefit in dialysis patients, while bleeding risk is substantially elevated. 2

• The 2013 KDIGO guidelines recommend offering antiplatelet agents only when atherosclerotic event risk clearly outweighs increased bleeding risk. 1
• A meta-analysis of primary prevention trials in non-dialysis CKD showed no difference in cardiovascular events but significant increases in both major and minor bleeding. 2
• One recent study in predialysis advanced CKD patients found aspirin use was associated with 15% higher risk of entering dialysis (HR 1.15) and 46% higher risk of death before dialysis (HR 1.46). 5

Critical Bleeding Risk Considerations

ESRD patients face substantially elevated bleeding risk with aspirin that must be weighed against cardiovascular benefit. 2

• In patients with CKD and atrial fibrillation requiring oral anticoagulation, concomitant low-dose aspirin substantially elevates bleeding risk and should be used very judiciously. 2
• Gastrointestinal bleeding risk is increased even with low-dose aspirin, though enteric coating does not reduce this risk. 2
• Mandatory proton pump inhibitor therapy should be prescribed for all ESRD patients on aspirin who have additional bleeding risk factors. 1, 6

Practical Management Algorithm

Before prescribing aspirin in ESRD, systematically assess:

1. Indication: Is this secondary prevention (prior MI, stroke, or established CAD)? If yes, prescribe aspirin. If primary prevention only, do not prescribe. 1

2. Bleeding risk factors: Age >70 years, anemia or bleeding disorders, concurrent anticoagulation, history of GI ulcers or bleeding. 1

3. Absolute contraindications: Active bleeding, recent GI bleeding without adequate control, severe coagulopathy, aspirin allergy. 2, 6

4. Monitoring: Check hemoglobin and platelet counts at baseline and periodically; discontinue if platelets fall below 50,000/μL. 6

Common Pitfalls to Avoid

• Do not prescribe aspirin for primary prevention in dialysis patients without compelling cardiovascular indications—the evidence does not support benefit. 2, 1
• Do not use doses exceeding 100 mg daily in ESRD patients, as higher doses increase bleeding without additional cardiovascular benefit. 2, 1
• Do not combine aspirin with other NSAIDs in any ESRD patient, as this dramatically increases acute kidney injury and bleeding risk. 1
• Do not reflexively discontinue aspirin in ESRD patients with established CAD based solely on renal function—the secondary prevention benefit persists. 2, 3

Special Perioperative Considerations

For ESRD patients undergoing renal transplantation, decisions on continuing aspirin perioperatively must be individualized based on indication and bleeding risk, though some programs routinely continue low-dose aspirin. 2