Thromboembolic prophylaxis in kidney failure patients with atrial fibrillation undergoing hemodialysis: from risk stratification to decision making on anticoagulants or left atrial appendage closure. A position paper endorsed by the Italian Society of Nephrology.

Atrial fibrillation (AF) is highly prevalent in patients with kidney failure (KF) who are undergoing hemodialysis (HD). All patients with AF and a thromboembolic risk score (CHA2DS2-VA) of two or more should be prescribed oral anticoagulant therapy (OAC), according to cardiology guidelines. However, there are no randomized controlled trials (RCTs) demonstrating that OAC protects against thromboembolic events in HD patients. Furthermore, evidence from observational studies is insufficient to demonstrate the benefits of OAC for preventing thromboembolism in HD patients with AF. Instead, it suggests that OAC is associated with an increased risk of bleeding in these patients. Left atrial appendage closure (LAAC) has been proposed as a means of preventing thromboembolic events in patients with AF. RCTs conducted in populations with preserved kidney function have demonstrated that the procedure is not inferior to OAC in terms of efficacy, and is associated with greater safety. Although no RCTs have tested the safety and efficacy of LAAC in KF patients undergoing HD, some observational studies suggest that LAAC has a similar efficacy profile in patients with and without KF. However, a higher incidence of peri-procedural complications has been reported. Observational studies comparing the efficacy and safety of LAAC with OAC in KF patients have shown a similar or reduced incidence of thromboembolism and bleeding in patients undergoing the procedure. The purpose of this Position Paper is to provide comprehensive, evidence-based information on the advantages and limitations of LAAC in KF patients with AF undergoing HD.