title: Atrial fibrillation in dialysis patients: time to abandon warfarin?
abstract: Atrial fibrillation (AF) is a frequent clinical complication in dialysis patients, and warfarin therapy represents the most common approach for reducing the risk of stroke in this population. However, current evidence based on observational studies, offer conflicting results, whereas no randomized controlled trials have been carried out so far. Additionally, many clinicians are wary of the possible role of warfarin as vascular calcification inducer and its potential to increase the high risk of bleeding among patients on dialysis. Ideally the most promising therapy would be based on direct inhibitors of factor IIa or Xa; however, at the moment, none of these drugs can be safely prescribed in dialysis patients, because of their potentially dangerous accumulation, and the lack of sufficient experience with apixaban or rivaroxaban, two drugs showing a favorable pharmacokinetic profile in end-stage renal disease. Hence, the use of vitamin K inhibitors is currently the only pharmacological option for stroke prevention in dialysis patients with atrial fibrillation, leaving the clinicians in a management conundrum.This review discusses the trade-offs implicated in warfarin use for this population, the promises of newly developed drugs, the role of dialysis as atrial fibrillation trigger, as well as potential non-pharmacological management options suitable in selected clinical situations.
authors.affiliation: Dialysis Unit NephroCare Simone Martini, Milan - Italy.
authors.forename: Diego
authors.initials: D
authors.lastname: Brancaccio
authors.affiliation: Fresenius Medical Care, Palazzo Pignano - Italy.
authors.forename: Luca
authors.initials: L
authors.lastname: Neri
authors.affiliation: Fresenius Medical Care, Palazzo Pignano - Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Bellocchio
authors.affiliation: Fresenius Medical Care, Palazzo Pignano - Italy.
authors.forename: Carlo
authors.initials: C
authors.lastname: Barbieri
authors.affiliation: Fresenius Medical Care, Palazzo Pignano - Italy.
authors.forename: Claudia
authors.initials: C
authors.lastname: Amato
authors.affiliation: Fresenius Medical Care, Palazzo Pignano - Italy.
authors.forename: Flavio
authors.initials: F
authors.lastname: Mari
authors.affiliation: Fresenius Medical Care, Bad Homburg - Germany.
authors.forename: Bernard
authors.initials: B
authors.lastname: Canaud
authors.affiliation: Fresenius Medical Care, Bad Homburg - Germany.
authors.forename: Stefano
authors.initials: S
authors.lastname: Stuard
mesh_terms: D000284:Administration, Oral; D000925:Anticoagulants / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000209:etiology / Q000517:prevention & control*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications / Q000628:therapy*; D006435:Renal Dialysis / Q000009:adverse effects*; D020521:Stroke / Q000209:etiology / Q000517:prevention & control; D014859:Warfarin / Q000627:therapeutic use*
chemical_list: D000925:Anticoagulants; D014859:Warfarin