An international panel of clinical experts has published comprehensive guidelines for managing oral anticoagulation in patients with atrial fibrillation on hemodialysis. The recommendations address the unique anticoagulation challenges faced by this high-risk group.

In the study, published in Clinical Kidney Journal, investigators proposed replacing the traditional CHA2DS2-VASc score with a "Dialysis Risk Score," assigning points for prior stroke (3 points), diabetes (1 point), age > 75 years (1 point), and recent gastrointestinal bleeding (–1 point). While promising, the Dialysis Risk Score has not yet been validated in hemodialysis (HD) populations.

The panel recommended direct oral anticoagulants (DOACs) over vitamin K antagonists (VKAs), specifically dose-adjusted apixaban (2.5 mg twice daily) or rivaroxaban (10 mg daily). However, data on the efficacy of DOACs in patients on HD remain limited. Findings from the RENAL-AF, VALKYRIE, and AXADIA trials highlighted varying bleeding risks associated with anticoagulants, complicating treatment decisions.

Regular reassessments of anticoagulation indication and bleeding risk every 3 to 6 months, instead of annually, were advised. The investigators emphasized the importance of shared decision-making and acknowledged that no anticoagulation may be appropriate for some patients.

Recent trials of factor XI inhibitors, such as the CONVERT and RE-THINC studies, showed favorable safety profiles but required further efficacy data. Meanwhile, ongoing randomized trials aim to compare oral anticoagulation vs no anticoagulation in patients with atrial fibrillation with advanced chronic kidney disease.

For full transparency, the conflict-of-interest declarations from the panel are available in the published guidelines.