Efficacy and safety of antithrombotics in patients with atrial fibrillation undergoing hemodialysis: a nationwide cohort study in Korea

BACKGROUND: Atrial fibrillation and chronic kidney disease mutually interact, presenting distinct clinical dilemmas where the optimal risk-benefit profile of antithrombotic therapy remains undefined. METHODS: This study was conducted using the Korean Health Insurance Review and Assessment Service database in patients with atrial fibrillation undergoing hemodialysis. The primary outcomes included thromboembolism and intracranial hemorrhage rates, while major bleeding and all-cause death were secondary outcomes. Selecting patients not taking antithrombotics as a reference, Kaplan-Meier and Cox proportional hazard analyses were performed for those taking antiplatelets, direct oral anticoagulants (DOACs), and warfarin. The net clinical benefit was obtained by balancing the efficacy and safety of each antithrombotic therapy. One-fifth of the patients received antithrombotic therapy, with 67.1% using antiplatelet drugs. Warfarin was associated with an increased thromboembolic risk (HR 1.25; 95% CI, 1.01-1.56), while findings for DOACs remain inconclusive. In net clinical benefit analysis, with warfarin demonstrated the most unfavorable profile, and DOACs exhibited comparable net clinical benefit to antiplatelet agents (0.57; 95% CI, - 0.56-1.70). CONCLUSION: This study provides real-world evidence on the use of antithrombotic therapy in atrial fibrillation patients undergoing hemodialysis. The findings highlight the profound complexity and uncertainty in managing this high-risk population, underscoring the importance for comprehensive assessment, individualized treatment approaches, and further dedicated research to establish optimal prevention and treatment strategies.