Antiplatelet in CKD

Aspirin

• Long-term aspirin therapy reduces the risk of subsequent myocardial infarction (MI), stroke, and vascular death among patients without CKD
• There are fewer data related to the effectiveness and safety of antiplatelet therapy in patients with CKD
• The best data come from a meta-analysis of 27,139 patients with CKD who participated in 50 randomized trials that tested the efficacy of antiplatelet agents (mostly aspirin) for prevention of CVD
• Antiplatelet therapy significantly reduced the incidence of fatal or nonfatal myocardial infarction as compared with either placebo or no therapy (6.7 versus 7.0 percent, or 3 myocardial infarctions prevented for every 1000 patients treated).
• However, antiplatelet therapy also significantly increased the rate of major bleeding (4.4 versus 2.9 percent, or 15 additional major bleeding events for every 1000 patients treated).
• Antiplatelets had no effect on stroke or mortality.
• The results were similar in patients of all CKD stages.
• Based upon these data, we suggest that decisions about antiplatelet therapy to prevent cardiovascular disease in patients with CKD be individualized depending upon the patient's overall risk for CHD (for example, a prior history of myocardial infarction) and for bleeding, and also upon their preferences.
• This suggestion is broadly consistent with guidelines made by the Kidney Disease Improving Global Outcomes (KDIGO) report on the management of CKD
• The prescription of low-dose aspirin is probably safe in most patients with CKD

Clopidogrel

• The current ACC/AHA guidelines recommend the use of clopidogrel in patients with ACS.
• No specific recommendations exist for the adjustment of clopidogrel dosage in renal insufficiency.
• A post-hoc analysis from the CREDO (Clopidogrel for Reduction in Events During Observation) trial, patients with mild and moderate CKD did not have any significant difference in outcomes (mild 10.3 % vs. 12.8%, p = 0.30; moderate 17.8% vs. 13.1%, p = 0.24) with increased risk of bleeding with clopidogrel
• A post-hoc analysis of the CURE (Clopidogrel in Unstable Angina to Prevent Recurrent Events) trial showed no interaction between clopidogrel and renal function (p value for homogeneity 0.11). 
• However, there was no significant benefit from using clopidogrel for patients in the lowest tertile (relative risk: 0.89 [95% confidence interval [CI]: 0.76 to 1.05]), and patients in this group had a significant increase in minor bleeding (hazard ratio: 1.5, 95% CI: 1.21 to 1.86) and blood transfusion (3.5%).

References:

1. www.uptodate.com
2. Safety and Efficacy of Anticoagulants in Kidney Disease
3. http://www.medscape.com/viewarticle/753721_2