Can antiplatelet medication be used for the treatment of bilateral peripheral arterial stenosis in a patient with End-Stage Renal Disease (ESRD) on hemodialysis (HD)?

From the Guidelines

Antiplatelet medication can be used for the treatment of bilateral peripheral arterial stenosis in a patient on dialysis, with single antiplatelet therapy reducing the risk of major adverse cardiovascular events (MACE) in patients with symptomatic peripheral artery disease (PAD). The recommended first-line antiplatelet therapy is typically aspirin at a dose of 75-100 mg daily, as it has been shown to reduce the risk of MACE in patients with PAD, although recent trials have also demonstrated the efficacy of P2Y12 inhibitors such as clopidogrel and ticagrelor in this patient population 1. For patients who cannot tolerate aspirin, clopidogrel 75 mg daily is an alternative, and for higher-risk patients, dual antiplatelet therapy with aspirin plus clopidogrel may be considered for a limited duration following endovascular interventions, though this increases bleeding risk.

When prescribing these medications for dialysis patients, dose adjustments are generally not required for aspirin, but careful monitoring for bleeding complications is essential as uremic patients have inherently higher bleeding risks 1. Antiplatelet therapy works by preventing platelet aggregation and thrombus formation, which helps maintain vessel patency and reduce the risk of thrombotic events in stenosed arteries. Key considerations in the management of bilateral peripheral arterial stenosis in dialysis patients include:

• The use of single antiplatelet therapy with aspirin or a P2Y12 inhibitor to reduce the risk of MACE
• Careful monitoring for bleeding complications, particularly in patients with uremia
• Consideration of dual antiplatelet therapy for higher-risk patients following endovascular interventions
• Regular monitoring of the patient's peripheral circulation through clinical assessment and vascular studies to evaluate treatment efficacy
• Management of other cardiovascular risk factors, including lipid control, blood pressure management, smoking cessation, and diabetes control.

The most recent guidelines recommend the use of antiplatelet therapy in patients with symptomatic PAD, including those on dialysis, to reduce the risk of MACE and improve outcomes 1. However, the choice of antiplatelet agent and the duration of therapy should be individualized based on the patient's risk factors and clinical presentation.

From the FDA Drug Label

The CAPRIE trial was a 19,185-patient, 304-center, international, randomized, double-blind, parallel-group study comparing clopidogrel (75 mg daily) to aspirin (325 mg daily) To be eligible to enroll, patients had to have: 1) recent history of myocardial infarction (within 35 days); 2) recent histories of ischemic stroke (within 6 months) with at least a week of residual neurological signs; and/or 3) established peripheral arterial disease (PAD).

The use of antiplatelet medication, such as clopidogrel, may be considered for the treatment of peripheral arterial stenosis in patients on dialysis, as it has been shown to be effective in reducing the risk of ischemic events in patients with established peripheral arterial disease (PAD) in the CAPRIE trial 2. However, it is essential to note that the CAPRIE trial did not specifically study patients on dialysis.

• The CAPRIE trial compared clopidogrel to aspirin in patients with recent myocardial infarction, recent ischemic stroke, or established peripheral arterial disease (PAD).
• The trial demonstrated that clopidogrel was more effective than aspirin in reducing the risk of ischemic events in patients with PAD.
• However, the trial did not provide specific information on the use of antiplatelet medication in patients on dialysis with bilateral peripheral arterial stenosis.

Therefore, a conservative clinical decision would be to consider the use of antiplatelet medication, such as clopidogrel, for the treatment of peripheral arterial stenosis in patients on dialysis, but with caution and careful consideration of the individual patient's risk factors and medical history.

From the Research

Treatment of Bilateral Peripheral Arterial Stenosis in Patients on Dialysis

The use of antiplatelet medication for the treatment of bilateral peripheral arterial stenosis in patients on dialysis is a complex issue. Several studies have investigated the effectiveness and safety of antiplatelet therapy in patients with end-stage renal disease undergoing dialysis.

• Effectiveness of Antiplatelet Therapy: A study published in 2014 3 found that antiplatelet therapy, especially aspirin, offers safe and effective treatment for ischemic stroke prevention in patients with end-stage renal disease undergoing dialysis.
• Aspirin as the Drug of Choice: Another study published in 2013 4 suggested that aspirin is still the drug of choice for the management of patients with peripheral arterial disease, although its efficacy is uncertain in PAD patients.
• Antiplatelet Agents in Hemodialysis: A study published in 2017 5 found that current data do not support a protective effect of antiplatelet administration in hemodialytic patients as primary prevention of cardiovascular mortality, but aspirin may be reasonable to use in HD patients with careful evaluation of the bleeding risk.
• Aspirin Prescription and Outcomes: A study published in 2007 6 found that aspirin was associated with decreased risk of stroke in all patients, but increased risk of myocardial infarction and cardiac event, with no increase in gastrointestinal bleeding.

Key Findings

• Antiplatelet therapy, especially aspirin, may be effective in preventing ischemic stroke in patients with end-stage renal disease undergoing dialysis.
• Aspirin is still the drug of choice for the management of patients with peripheral arterial disease, although its efficacy is uncertain in PAD patients.
• The use of antiplatelet agents in hemodialysis patients requires careful evaluation of the bleeding risk.
• Aspirin may decrease the risk of stroke, but may increase the risk of myocardial infarction and cardiac event in hemodialysis patients.

Considerations for Treatment

• The decision to use antiplatelet medication for the treatment of bilateral peripheral arterial stenosis in patients on dialysis should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history.
• Patients with end-stage renal disease undergoing dialysis may require careful monitoring for bleeding complications when using antiplatelet therapy.
• Further studies are needed to fully understand the effectiveness and safety of antiplatelet therapy in patients with peripheral arterial disease and end-stage renal disease undergoing dialysis.