Is anticoagulating haemodialysis patients with non‐valvular atrial fibrillation too risky?

Abstract

There is an increasing understanding of the risks from atrial fibrillation (AF) in the current era. In patients with end-stage renal disease (ESRD) on dialysis, the prevalence of AF is significantly higher compared to the general population and those with earlier stages of CKD. Although anticoagulation of these patients may seem appropriate, there is a lack of conclusive evidence that it provides the same protection from thromboembolic complications as it does in patients not on dialysis. In addition, the increased risk of bleeding in patients requiring dialysis makes the use of anticoagulants less favourable. This article aims to discuss the problem of AF in dialysis patients, summarise the current evidence around the use of oral anticoagulants for AF in ESRD and provide some practical suggestions on management of AF in the haemodialysis population.

Venous thromboembolism in multiple myeloma – choice of prophylaxis, role of direct oral anticoagulants and special considerations

“…Separate to proteinuria and the nephrotic syndrome, chronic renal impairment is not only a risk factor for thrombosis, but subsequent anticoagulation also poses challenges in this demographic, who are at greater risk of haemorrhagic complications (Parker et al , ). Most bleeding risk assessment scores include renal impairment as a risk factor.…”

“…These have been more extensively studied than the thrombotic issues, and involve defective vascular integrity, acquired factor X deficiency and acquired von Willebrand syndrome (Bever et al, 2016), and clearly have to be borne in mind when managing thrombotic risk in affected individuals. Separate to proteinuria and the nephrotic syndrome, chronic renal impairment is not only a risk factor for thrombosis, but subsequent anticoagulation also poses challenges in this demographic, who are at greater risk of haemorrhagic complications (Parker et al, 2018). Most bleeding risk assessment scores include renal impairment as a risk factor.…”

The use of direct oral anticoagulants in chronic kidney disease

“…For the purpose of the DOAC clinical studies, definitions of renal function are: mild impairment 50–80 ml/min, moderate impairment 30–49 ml/min and severe impairment less than 30 ml/min. This review will not cover anticoagulation in patients on dialysis, which was recently reviewed (Parker et al , ).…”

Clarification of the use of rivaroxaban in renal patients

“…I would like to thank Parker et al () for a thorough review of the use of rivaroxaban in renal patients, an important topic. However, I would like to address a few of their statements regarding the use of rivaroxaban and apixaban in this population.…”

“…However, I would like to address a few of their statements regarding the use of rivaroxaban and apixaban in this population. The following are some clarifications that should be noted as the data provided in the review (Parker et al , ) appears to be out of date. The pivotal Phase 3 studies for both apixaban and rivaroxaban excluded patients categorized as having severe renal impairment or end‐stage renal disease (ESRD).…”