Atrial Fibrillation, Atrial Flutter, Dialysis Patients, End Stage Kidney Disease (ESRD)
Conditions
Keywords
atrial fibrillation, end stage renal disease, end stage kidney disease, dialysis, oral anticoagulation, apixaban, no oral anticoagulation
Brief summary
People receiving dialysis are more likely to develop atrial fibrillation (AF), an irregular heartbeat that increases the risk of stroke. Blood-thinning medications (anticoagulants) are commonly used to prevent strokes in people with AF, but it is not known whether they are beneficial for people receiving dialysis because this group has not been well represented in previous clinical trials. As a result, healthcare providers do not have clear evidence to guide treatment decisions. The SAFE-D2 study will compare two approaches to preventing stroke in adults receiving maintenance hemodialysis or peritoneal dialysis who have non-valvular AF and are at increased risk of stroke. Participants will be randomly assigned (by chance) to receive either apixaban, an oral blood thinner, or no oral anticoagulant, while continuing to receive their usual dialysis and medical care. The main goal of the study is to determine whether apixaban is more effective than no oral anticoagulant at reducing the risk of stroke or blood clots traveling to other parts of the body (systemic embolism). The study will also compare the two approaches with respect to survival, heart-related complications, major bleeding and other bleeding events, hospitalizations, dialysis access complications, quality of life, and the overall balance of benefits and risks. Approximately 848 participants from Canada, Brazil, and Israel will take part in the study. The results of SAFE-D2 are expected to provide important evidence to help patients, families, and healthcare providers make informed decisions about stroke prevention for people receiving dialysis who have atrial fibrillation.
Detailed description
Atrial fibrillation (AF) is common among people receiving maintenance dialysis and is associated with an increased risk of ischemic stroke, systemic embolism, cardiovascular events, and death. Although oral anticoagulation is recommended for many patients with AF in the general population, the benefits and risks of anticoagulation in people receiving dialysis remain uncertain because this population has been excluded from most pivotal randomized trials. Observational studies have reported conflicting findings, and current guideline recommendations differ, resulting in substantial variation in clinical practice. The Strategies for the Management of Atrial Fibrillation in patiEnts receiving Dialysis 2 (SAFE-D2) trial is designed to address this important evidence gap. The study will evaluate whether a treatment strategy using apixaban is superior to a strategy of no oral anticoagulation for the prevention of ischemic stroke and systemic embolism in adults receiving maintenance hemodialysis or peritoneal dialysis who have non-valvular AF and an elevated risk of stroke. SAFE-D2 is an investigator-initiated, international, multicenter, pragmatic, randomized, open-label trial with blinded adjudication of study outcomes. Approximately 848 participants will be randomly assigned in a 1:1 ratio to receive either apixaban or no oral anticoagulation, while continuing to receive standard dialysis and other routine medical care. The trial is designed to determine whether apixaban reduces the risk of ischemic stroke or systemic embolism while evaluating the overall balance between potential benefits and harms. In addition to thromboembolic events, the study will assess mortality, cardiovascular events, bleeding complications, hospitalizations, dialysis vascular access thrombosis, and patient-reported health-related quality of life. An independent Clinical Events Committee, blinded to treatment allocation, will adjudicate all major efficacy and safety outcomes according to prespecified definitions. SAFE-D2 builds on the feasibility established in the CIHR-funded SAFE-D pilot trial and reflects contemporary clinical practice by evaluating apixaban rather than warfarin. The results are expected to provide high-quality randomized evidence to inform clinical practice guidelines and support shared decision-making regarding stroke prevention in people receiving maintenance dialysis and atrial fibrillation.
Interventions
DRUGEliquis
The default starting dose of apixaban is 5 mg twice daily. Dose reduction to 2.5 mg twice daily is mandatory for participants who meet either of the following criteria at baseline or at any point during follow-up: * Age ≥80 years * Dialysis target (dry) weight ≤60 kg
No oral anticoagulation
Sponsors
Unity Health Toronto
Canadian Institutes of Health Research (CIHR)
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
To be eligible to participate in this trial, participants need to satisfy ALL these inclusion criteria: 1. Age ≥18 years, 2. Kidney failure treated with hemodialysis or peritoneal dialysis for at least 90 days, 3. A history of non-valvular AF or atrial flutter (AFL) defined as one of the following: 1. AF/AFL on an ECG at enrollment. 2. ≥2 episodes of AF/AFL on cardiac diagnostics with each episode lasting ≥30 seconds and occurring ≥24 hours apart. 3. One episode of AF/AFL on cardiac diagnostics lasting ≥30 seconds, plus ≥1 separate documented episode in the medical record. 4. One episode of AF (reported by cardiac diagnostics or documented in the medical record) plus treatment with an oral anticoagulant for stroke prevention as a result of AF/AFL; or 5. AF/AFL documented on one occasion in a cardiologist report. 4. Meet the CHA2DS2-VASc criteria (i.e. ≥2 for men and ≥3 for women)
Exclusion criteria
Potential participants must have NONE of the following
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Stroke or systemic embolism | 5 years | The primary outcome is time to first confirmed ischemic stroke or systemic embolism. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Time to all-cause death | 5 years | — |
| Time to first occurrence of ischemic stroke, systemic embolism, or all-cause death | 5 years | Time from randomization to the first occurrence of confirmed ischemic stroke, systemic embolism, or death from any cause. |
| Time to first occurrence of ischemic stroke, systemic embolism, or cardiovascular death | 5 years | Time from randomization to the first occurrence of confirmed ischemic stroke, systemic embolism, or cardiovascular death. |
| Time to first occurrence of ischemic stroke, systemic embolism, myocardial infarction, or all-cause death | 5 years | Time from randomization to the first occurrence of confirmed ischemic stroke, systemic embolism, myocardial infarction, or death from any cause. |
| Time to first ischemic stroke | 5 years | Time from randomization to the first adjudicated ischemic stroke. |
| Time to first systemic embolism | 5 years | Time from randomization to the first adjudicated systemic embolism. |
| Time to cardiovascular death | 5 years | — |
| Time to first myocardial infarction | 5 years | — |
| Net clinical benefit defined as the composite of stroke, systemic embolism, or major bleeding (ISTH definition). | 5 years | Time to first occurrence of ischemic stroke, systemic embolism, or major bleeding (ISTH definition). |
| Time to first dialysis vascular access thrombosis | 5 years | Time from randomization to the first clinically adjudicated thrombosis of an arteriovenous fistula or graft requiring surgical or endovascular intervention, such as thrombectomy or angioplasty, or resulting in permanent access loss. |
| Time to first major bleeding event | 5 years | Time from randomization to the first major bleeding event meeting International Society on Thrombosis and Haemostasis (ISTH) criteria. |
| Time to first major or clinically relevant non-major bleeding event | 5 years | Time from randomization to the first occurrence of major bleeding or clinically relevant non-major bleeding according to ISTH definitions. |
| Time to first clinically relevant non-major bleeding event | 5 years | Time from randomization to the first clinically relevant non-major bleeding event according to ISTH criteria. |
| Time to first intracranial hemorrhage | 5 years | Time from randomization to the first adjudicated intracranial hemorrhage, including intracerebral hemorrhage, subarachnoid hemorrhage, subdural hematoma, or other primary intracranial hemorrhage confirmed by neuroimaging or autopsy. |
| Time to fatal bleeding | 5 years | Time from randomization to the first fatal bleeding event. |
| Number of all-cause unplanned hospitalizations | 5 years | Total number of all-cause unplanned hospitalizations occurring during study follow-up, including recurrent hospitalizations. An all-cause unplanned hospitalization is defined as any non-elective admission to an acute care hospital lasting ≥24 hours, regardless of cause. Elective or planned admissions or procedures, routine day procedures or outpatient visits not requiring overnight admission, protocol-mandated assessments, routine health evaluations, and admissions solely for social, administrative, or logistical reasons are excluded. Transfers between hospital units or facilities as part of the same episode of care are considered a single hospitalization. |
Contacts
CONTACTZiv Harel, MD
CONTACTIvana Prce
PRINCIPAL_INVESTIGATORZiv Harel, MD
Unity Health Toronto
Outcome results
None listed