Direct Oral Anticoagulants for Atrial Fibrillation in Patients Receiving Hemodialysis: A Review and Discussion of Evidence

An optimal strategy for managing thrombotic risk in patients with atrial fibrillation (AF) receiving hemodialysis (HD) remains uncertain. To date, the literature has not shown definitive benefit from the use of oral anticoagulants for AF in patients receiving HD. Furthermore, attaining appropriate time in the therapeutic range with vitamin K antagonists is more difficult in patients with end-stage renal disease, and their use may be harmful due to an increased risk of bleeding and vascular calcification. Direct oral anticoagulants appear safer and possibly more effective than vitamin K antagonists. Although more data are available on apixaban than other DOACs, studies have not shown direct evidence to favor apixaban over rivaroxaban. Available risk prediction tools to identify patients who would benefit from anticoagulation therapy perform poorly in patients with chronic kidney disease. As such, better thromboembolic and bleeding risk prediction tools for this subgroup are needed. This article will present and discuss evidence on the use of oral anticoagulants for AF in patients receiving HD, including that from recent randomized controlled trials, meta-analyses, and relevant pharmacokinetic studies. The optimal dosing of DOACs in this patient population will also be explored.