Anticoagulation for Atrial Fibrillation in End-stage Kidney Disease

Abstract

Atrial fibrillation (AF) is the most common arrhythmia in the general population and it has been found to have a higher prevalence in end-stage kidney disease (ESKD). It is associated with a higher risk of stroke and mortality compared to those without AF. Patients with ESKD have generally been excluded from randomized controlled trials (RCTs) evaluating the efficacy of anticoagulation in reduction of stroke risk. Current observational evidence for anticoagulation for AF in the ESKD population has yielded conflicting results, but in aggregate favours a lack of benefit in stroke risk reduction with an increase in bleeding risk. There are also reports that warfarin use in ESKD patients on dialysis is associated with greater International Normalised Ratio (INR) variability and increased risk of vascular calcification and calciphylaxis (uraemic calcific arteriolopathy). RCTs are required to assess the net clinical benefit of anticoagulation in this group.

Oral Anticoagulants in Patients With Atrial Fibrillation and End-Stage Renal Disease

“…37 Furthermore, the interaction with heparin given peri-dialysis makes it challenging to stay within therapeutic INR for patients with ESRD. 38 In summary, the available data are weak and conflicting regarding the need for routine use of warfarin. However, it is the best agent to use when a stable INR can be maintained and the bleeding risk is modest.…”

“…37 Furthermore, the interaction with heparin given peri-dialysis makes it challenging to stay within therapeutic INR for patients with ESRD. 38…”