Direct Oral Anticoagulants in Patients on Chronic Dialysis and Concomitant Atrial Fibrillation: A Common Clinical Impasse

Abstract

The most frequent arrhythmia treated is atrial fibrillation (AF), which necessitates the use of oral anticoagulants (OACs) to reduce the risk of thromboembolism and stroke. Patients with chronic kidney disease are more likely to develop AF, with a 10% frequency among those on chronic dialysis. Warfarin is the most widely prescribed OAC for individuals with end-stage kidney disease (ESKD). On the other hand, direct OACs (DOACs) are generally safer than warfarin, with fewer fatal bleeding events and a fixed dose that does not require close international normalized ratio (INR) monitoring. For those patients, warfarin and apixaban appear to be FDA-approved, whereas dabigatran, rivaroxaban, and edoxaban are not recommended yet. Due to a lack of large randomized studies, data from major trials cannot be extended to dialysis patients. In this review, we summarize the available data and literature referring to patients on chronic hemodialysis with concomitant AF. Due to the scarcity of data, we try to assist clinicians in selecting the appropriate therapy according to the specific characteristics of each patient. Finally, future directions are provided in two key areas of focus: left atrial appendage closure therapies and genetic research.

The safety and efficacy of direct oral anticoagulants among chronic kidney disease patients on dialysis with non-valvular atrial fibrillation: a meta-analysis

“…There is a huge debate regarding the anticoagulation strategy among patients with atrial fibrillation on chronic dialysis. There is a lack of consensus between the international guidelines (KDIGO 2012, ESC 2020, AHA/HRS 2019, CCS 2020, CHEST 2018), and most would either recommend a VKA or no anticoagulation while some guidelines state that standard or reduced dose apixaban may be used with caution ( 17 ) ( Table 5 ). In general, NOACs are NOT recommended among patients with advanced CKD (CrCl < 15 ml/min), more so those on hemodialysis.…”

Comparison of Effectiveness and Safety of Direct-Acting Oral Anticoagulants and Vitamin K Agonists in Patients With Atrial Fibrillation and End-Stage Kidney Disease: A Systematic Review and Meta-Analysis

“…Although warfarin offers favorable pharmacodynamic characteristics for patients with ESRD due to its hepatic elimination and resistance to dialysis, its unpredictable dose-response relationship may predispose patients to bleeding incidents. In addition to its narrow therapeutic window and the need for frequent international normalized ratio monitoring, warfarin contributes to arterial vascular calcification [ 24 ]. This phenomenon is thought to occur through the inhibition of the vitamin K-dependent enzyme matrix gamma-carboxyglutamate Gla protein, which typically inhibits calcification processes [ 25 ].…”