Anticoagulation in end-stage renal disease

Patients with end-stage renal disease face an increased thromboembolic risk but also have heightened susceptibility to bleeding. This dual risk poses a distinct challenge in managing conditions requiring anticoagulation. In this article, we summarize the most recent evidence on anticoagulation for patients with end-stage renal disease, focusing on stroke prevention in atrial fibrillation and the management of venous thromboembolic disease, and we highlight practical considerations for clinical decision-making. It remains unclear whether atrial fibrillation confers the same attributable risk of stroke in the end-stage renal disease population compared to the general population. The bleeding risk is also disproportionately high in kidney failure and the relative incidence of hemorrhagic stroke increases as renal function declines. All direct oral anticoagulants are eliminated by the kidneys in varying degrees and appropriate dose adjustment is required. Vitamin K antagonists should not be considered entirely safe and are probably not superior to direct oral anticoagulants for stroke prevention. There is increasing evidence that the risk of bleeding may be higher with vitamin K antagonists, compared with apixaban or rivaroxaban. However, given the relatively low risk of ischemic stroke and the high risk of bleeding, it is reasonable to avoid anticoagulation for stroke prevention for many of these patients. For the treatment of venous thromboembolic disease, parenteral anticoagulation followed by vitamin K antagonists remains the standard of care. Limited data exists with apixaban in this setting. For both indications though, the need remains for larger, randomized trials to guide management of anticoagulation in end-stage renal disease.