Aspirin Use in ESRD Patients
Yes, aspirin can and should be given to ESRD patients who have established cardiovascular disease (secondary prevention), but it is not recommended for primary prevention in this population.
Secondary Prevention: Clear Benefit
For ESRD patients with documented coronary artery disease, prior myocardial infarction, or prior stroke, continue low-dose aspirin (75-100 mg daily) indefinitely because the cardiovascular mortality reduction substantially outweighs bleeding risk. 1, 2
- In ESRD patients presenting with acute myocardial infarction, aspirin reduces 30-day mortality by 36% (RR 0.64; 95% CI 0.50-0.80), with similar benefit to non-ESRD patients. 3
- Observational data from dialysis patients with prior ischemic stroke shows aspirin reduces 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
- Post-transplant patients with known CAD should continue aspirin following ACC/AHA secondary prevention guidelines. 1
Primary Prevention: Not Recommended
Do not prescribe aspirin for primary prevention in ESRD patients because randomized trials show no cardiovascular benefit while bleeding risk is markedly increased. 1, 2, 5
- No randomized controlled trials have demonstrated efficacy of aspirin for primary prevention specifically in dialysis patients. 1
- Meta-analysis of CKD trials (including advanced stages) shows no reduction in cardiovascular events but significant increases in both major and minor bleeding with aspirin. 1
- A 5-year prospective cohort of 406 hemodialysis patients found no significant reduction in all-cause mortality (log rank p = 0.299), cardiovascular events, or stroke with aspirin 100 mg daily. 6
Dosing Recommendations
Use 75-100 mg aspirin once daily; no dose adjustment is required for renal impairment. 2, 5
- For acute coronary syndrome, give a loading dose of 150-300 mg orally, then maintain 75-100 mg daily. 5
- Do not exceed 100 mg daily—higher doses increase bleeding without additional cardiovascular benefit. 2
- Most clinical trials in CKD/ESRD used 75-100 mg daily with demonstrated safety at this range. 1
Bleeding Risk Assessment
Before prescribing aspirin in ESRD, systematically assess: age >70 years, anemia or bleeding disorders, concurrent anticoagulation or NSAIDs, history of gastrointestinal ulcers or bleeding, and recent uncontrolled bleeding. 2
- ESRD patients have substantially higher baseline bleeding risk due to uremic platelet dysfunction. 1
- The HOT trial subgroup analysis showed aspirin doubled major bleeding risk in patients with eGFR <45 mL/min/1.73 m². 1
- Absolute contraindications include active bleeding, recent uncontrolled GI bleeding, severe coagulopathy, and aspirin allergy. 2
Critical Pitfalls to Avoid
Do not withhold aspirin from ESRD patients with documented prior MI, stroke, or coronary revascularization—the secondary prevention benefit is established and mortality reduction outweighs bleeding risk. 2, 5, 3
Do not combine aspirin with other NSAIDs in ESRD patients, as this dramatically increases acute kidney injury risk and compounds bleeding risk. 2, 5
Do not prescribe aspirin for primary prevention in dialysis patients outside of clinical trials—the evidence shows no benefit and clear harm. 1, 2, 6
Perioperative Management for Renal Transplantation
Many transplant programs routinely continue low-dose aspirin perioperatively in ESRD patients when the indication is secondary prevention, though decisions must account for surgical bleeding risk. 1
- It is reasonable to continue aspirin indefinitely after renal transplantation in patients with known CAD (Class IIa recommendation). 1
- Surgeons often prefer to hold clopidogrel perioperatively due to bleeding concerns, but low-dose aspirin is frequently maintained. 1
Special Considerations
Approximately 44-50% of ESRD patients demonstrate aspirin resistance by platelet function testing, and these patients have 2.7-fold higher risk of major adverse events (HR 2.722; 95% CI 1.068-6.942). 7