Oral anticoagulation in atrial fibrillation and end-stage renal disease

Atrial fibrillation (AF) is the most common arrhythmia in the world. Prevalence is rising and co-morbidities like chronic kidney disease (CKD) are common. Oral anticoagulation (OAC) is used for stroke prevention in AF but limited to patients without reduced kidney function. Vitamin-K antagonists (VKA) and non-VKA oral anticoagulants (NOAC) are only available for patients with a glomerular filtration function (GFR) above 15 mL/min. In patients with lower GFR or on chronic hemodialysis limited data on efficacy in prevention of stroke is available. Observational data from large cohorts in the United States and Scandinavian countries hinted at increased risk for major bleedings without significant effects of mortality or strokes. The randomized-controlled VALKYRIE study showed that 10 mg of rivaroxaban (NOAC) was associated with less cardiovascular events compared with VKA. The randomized-controlled AXADIA-AFNET 7 study will compare apixaban 2.5 mg BID (NOAC) with VKA in patients with AF and chronic hemodialysis. Enrollment will end in June 2022 and the results will provide importance evidence in this field that has been noted for need for stronger evidence to adequately help AF patients with reduced kidney function.