Anticoagulation Management in Hemodialysis Patients with Atrial Fibrillation: A Clinical Dilemma

Atrial Fibrillation (AF) is the most common cardiac arrhythmia and is increasingly prevalent among patients on haemodialysis (HD). It presents a significant clinical challenge due to the elevated risks of both thromboembolic and bleeding events. Although the shift from Vitamin K Antagonists (VKAs) to Direct Oral Anticoagulants (DOACs) is well established in the general population and in patients with moderate Chronic Kidney Disease (CKD), uncertainty persists in HD patients due to limited evidence. This review synthesizes current evidence on anticoagulation therapy in HD patients with AF, evaluating safety, efficacy, and clinical guidelines to inform evidence-based decision-making. We reviewed current evidence, including randomized controlled trials (RCTs), observational studies, meta-analyses, and systematic reviews, on anticoagulation in HD patients with AF. Relevant articles published up to December 2024 were identified via PubMed, Cochrane Library, and EMBASE. Key clinical guidelines (KDIGO, ESH, ACC/AHA/ACCP/HPS) were also included. Overall, evidence in HD patients remains heterogeneous. Small RCTs evaluating DOACS have methodological limitations and conflicting results. However, meta-analyses and large cohort studies show that VKAs do not significantly reduce ischemic stroke or mortality in this population and may increase haemorrhagic risk; poor time-in-therapeutic range is a recurring problem. In contrast, accumulating evidence increasingly favors DOACs, with signals of lower bleeding and at least comparable stroke prevention. Left atrial appendage occlusion (LAAO) is an emerging option that may reduce stroke risk without long-term anticoagulation. While definitive randomized evidence in HD remains lacking, the current data balance suggests a cautious preference for DOACs over VKAs. Further adequately powered RCTs in HD are needed to solidify these recommendations.