Ten 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 with the general population. Thus, the benefit to risk ratio of either vitamin K antagonists or direct oral anticoagulants is less evident in HD than in non-CKD patients with AF. As a multidisciplinary panel of clinicians, we here propose 10 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.

Keywords: FXI inhibition; atrial fibrillation; hemodialysis; oral anticoagulation; risk stratification.

Figure 1:

Dialysis Risk Score. The Dialysis Risk Score assigns points to the factors that were significantly associated with subsequent stroke (previous stroke, diabetes and older age) and ignores the factors that were not (hypertension and heart failure) in the Dialysis Outcomes and Practice Patterns Study (DOPPS) [70]. The increased bleeding risk in HD patients is accounted for by including history of gastrointestinal bleeding during the previous year, since this is predictive of subsequent bleeding [8]. Most weight is given to a history of transient ischemic attack or ischemic stroke, since in our view these patients should receive OAC even if they experienced a major bleeding episode. The Dialysis Risk Score is an attempt to restrict OAC to HD patients with a favorable benefit–risk ratio but has not been validated in this population.

Figure 2:

FXI/XIa inhibition and DOAC in coagulation cascade. Simplified overview over the human coagulation system and site of action for novel FXI inhibition strategies and for DOAC. Figure adapted from Nopp et al. [71].