Anticoagulation for atrial fibrillation in patients on dialysis:  are the benefits worth the risks?
OBJECTIVE
Atrial fibrillation is common among patients with end-stage renal disease undergoing hemodialysis. Although oral anticoagulation is recommended for stroke prevention in most patients with atrial fibrillation, limited evidence is available to guide treatment in hemodialysis patients with this arrhythmia. We summarize the available evidence on the epidemiology of atrial fibrillation in dialysis patients and review the data on the effectiveness of oral anticoagulation in this population.


RESULTS
Atrial fibrillation is increasingly common in patients undergoing chronic hemodialysis, especially among older patients wherein one in six patients is diagnosed with this arrhythmia. Patients with atrial fibrillation experience double the mortality of otherwise similar patients without it. Few hemodialysis patients with atrial fibrillation receive oral anticoagulation, which is consistently associated with excess risks of hemorrhagic stroke. Observational studies did not detect a beneficial association of oral anticoagulation with the risk of ischemic stroke, with some studies describing higher risks of ischemic stroke among warfarin users. New therapeutic options including one oral direct thrombin inhibitor and two oral factor Xa inhibitors have become available, but were not tested in patients with advanced kidney disease.


CONCLUSIONS
Atrial fibrillation is increasingly common in patients undergoing hemodialysis, yet little is known about the optimal management of these patients. The current evidence does not support net benefits from oral anticoagulation in the dialysis population.
Division of Nephrology, Stanford University School of Medicine and Veterans Affairs Palo Alto Healthcare System, Palo Alto, California 94304, USA.
Jenny I
JI
Shen
Mintu P
MP
Turakhia
Wolfgang C
WC
Winkelmayer
D000284:Administration, Oral; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000188:drug therapy* / Q000453:epidemiology; D006801:Humans; D020300:Intracranial Hemorrhages / Q000139:chemically induced; D007676:Kidney Failure, Chronic / Q000453:epidemiology / Q000628:therapy*; D010818:Practice Patterns, Physicians'; D006435:Renal Dialysis / Q000009:adverse effects; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000453:epidemiology / Q000517:prevention & control*; D016896:Treatment Outcome
D000925:Anticoagulants