Atrial fibrillation in patients on hemodialysis has a prevalence of up to 27% and a stroke incidence of approximately 5%, while evidence for oral anticoagulation remains contradictory.
Does oral anticoagulation improve stroke prevention without excessive hemorrhage risk in patients with end-stage renal disease on hemodialysis with atrial fibrillation?
This review highlights the lack of clear evidence for anticoagulation in hemodialysis patients with atrial fibrillation and discusses the potential role of DOACs based on their pharmacokinetic profiles.
Atrial fibrillation (AF) is a frequent comorbid condition in patients with end-stage renal disease on hemodialysis (HD) with a prevalence of up to 27%. The incidence rate of stroke in AF patients on HD is approximately 5%. The AF-associated risk of stroke is a major clinical challenge because current evidence for anticoagulation in HD patients with AF is based on observational data. Results from these observational studies is largely contradictory because they do not show a clear benefit of vitamin K antagonists over no treatment in terms of stroke prevention, and they show an increased risk of hemorrhage associated with anticoagulation treatment in HD patients. HD patients were not included in randomized trials of the direct oral anticoagulants (DOACs), and therefore there is no evidence to support efficacy and safety of DOACs compared to vitamin K antagonists in HD patients. The pharmacological characteristics of DOACs are of particular interest in the HD setting. The factor Xa inhibitors rivaroxaban, apixaban, and edoxaban are not predominantly eliminated via the kidneys. The thrombin inhibitor dabigatran is 80% eliminated via the kidneys but is dialyzable due to its low protein binding. In this narrative review, we examine the current state of evidence regarding the prevalence of AF in patients on HD, the associated risk of stroke, and the efficacy and safety of anticoagulation for stroke prevention in the HD setting. Further, based on the pharmacokinetic properties of DOACs, we discuss their potential use in patients on HD and ongoing randomized trials.
Königsbrügge et al. (Mon,) conducted a review in Atrial fibrillation in end-stage renal disease on hemodialysis. Oral anticoagulation was evaluated. Atrial fibrillation in patients on hemodialysis has a prevalence of up to 27% and a stroke incidence of approximately 5%, while evidence for oral anticoagulation remains contradictory.