10 tips to manage oral anticoagulation in hemodialysis patients with atrial fibrillation

Abstract Patients with chronic kidney disease (CKD) have a high incidence and prevalence of atrial fibrillation (AF). While general treatment strategies for AF may largely be transferred to patients with mild to moderate CKD, patients with advanced CKD—particularly hemodialysis (HD) patients—with AF pose substantial therapeutical challenges to cardiologists and nephrologists. The arguably greatest dilemma is the very limited evidence on appropriate strategies for prevention of stroke and systemic embolism in HD patients with AF, since the risk for both thromboembolic events without oral anticoagulation and severe bleeding events with oral anticoagulation are substantially increased in advanced CKD, compared to the general population. Thus, the benefit to risk ratio of either vitamin-K antagonists or direct oral anticoagulants (DOAC) is less evident in HD than in non-CKD patients with AF. As a multidisciplinary panel of clinicians, we here propose ten tips that may help our colleagues to navigate between the risk of undertreatment—exposing CKD patients with AF to a high stroke risk—and overtreatment—exposing the very same patients to a prohibitively high bleeding risk. These tips include ideas on alternative risk stratification strategies and novel treatment approaches that are currently in clinical studies—such as Factor-XI inhibitors or Left Atrial Appendage closure—and may become game-changers for HD patients with AF.