Stuck Between a Rock and a Hard Place: Anticoagulation in End-Stage Kidney Disease Patients With Atrial Fibrillation

Anticoagulation using vitamin K antagonists or direct oral anticoagulants is an established treatment option for stroke prevention in patients with atrial fibrillation (AF). Although AF is common in patients with end-stage kidney disease (ESKD), the role of anticoagulation in stroke prevention has not been established in this group of patients. Major clinical trials have excluded patients with advanced kidney disease and this explains the significant lack of evidence-based guidelines to aid clinical decisions in the management of AF in patients with ESKD. Results from smaller studies and meta-analyses involving ESKD patients have not shown any significant advantage of using anticoagulants in preventing thromboembolic events. Moreover, anticoagulation has been associated with a higher risk of significant bleeding in dialysis patients. Therefore, caution and individualised treatment plans are suggested when considering ESKD patients' anticoagulation. Ongoing clinical trials might illuminate this situation and help formulate more definitive guidance for anticoagulation use in ESKD patients. In summary, insufficient and inconclusive data, which results in the lack of evidence-based guidelines and the unique hemostatic paradox intrinsic to ESKD, muddle the management of AF in ESKD. This underscores the need to consolidate and synthesize data from past and ongoing studies to compare existing treatment options and identify gaps in knowledge that can direct further studies.