From the Chair: Managing Nonvalvular Atrial Fibrillation in Dialysis Patients: What Should You Do?

Ajay K. Singh, MBBS, FRCP, MBA

The Controversies in Nephrology series1-7 in the Clinical Journal of the American Society of Nephrology (CJASN) covered a topic that virtually every nephrologist has had to wrestle with, namely how to manage a dialysis patient who develops nonvalvular atrial fibrillation (NVAF). The articles are outstanding and thoughtful.
A stroke from NVAF could have devastating consequences (that is, if the patient survives). If you decide to anticoagulate and the patient has a bleed, you have potentially harmed the patient. The Greek mythological idiom Scylla and Charybdis comes to mind: this is about having to choose between two evils.
NVAF is the most common arrhythmia in chronic kidney disease (CKD) patients and is 10 to 20 times more common among dialysis patients than it is in the general population. Its incidence is increasing, in part because of growth in the end-stage renal disease (ESRD) population, but also because older patients are being initiated on dialysis and patients on dialysis have greater longevity.
Among stage 3 to 5 patients with CKD, the prevalence of NVAF is estimated to be approximately 8%. However, in CKD Stage 5d patients (those on dialysis), the latest numbers suggest the prevalence to be ~25% (earlier estimates had suggested a prevalence of >30%).
While there is some consensus on how and when to treat NVAF in CKD patients not on dialysis, there is little consensus on what to do in dialysis patients. Guidelines disagree, because there are no randomized trials, and, as the CJASN articles point out, we are guided by retrospective studies and administrative databases.
Vaibhav Keskar and Manish Sood4 argue: “A conservative approach [in dialysis patients] without the use of anticoagulants is warranted.”
Nisha Bansal and colleagues5: “Without well conducted clinical trials specifically in patients with ESRD, it is impossible to definitely rule out anticoagulation for patients with ESRD and AF.”

So, what should you do?
In patients with CKD stage 5d (patients on dialysis), while
UptoDate recommends “no anticoagulation,” the 2014 American Heart Association/American College of Cardiology/Heart Rhythm Society AF guideline recommends (weakly) anticoagulation. However, the Kidney Disease Improving Global Outcomes guidelines state: “Until new data become available, and in contrast to previous National Kidney Foundation Kidney Disease Outcomes Quality Initiative recommendation 9.1, routine anticoagulation of CKD 5d patients with atrial fibrillation for primary prevention of stroke is not indicated7.”
What do I do in my practice? I treat patients who are not at high risk of bleeding with warfarin aiming for an international normalized ratio of 2:3. For those patients who are at high risk of bleeding and those at high risk of falls, I use the Xa inhibitor apixaban at a dose of 2.5 mg twice a day.
All of that said, what we really need are randomly controlled trials to decide what we need to do.

References

  1. Palevsky PM. Use of Oral Anticoagulation in the Management of Atrial Fibrillation in Patients with ESRD: Introduction. Clin J Am Soc Nephrol. 2016 Nov 7;11(11):2078.
  2. Herzog CA. Use of Oral Anticoagulation in the Management of Atrial Fibrillation in Patients with ESRD: Verdict 2. Clin J Am Soc Nephrol. 2016 Nov 7;11(11):2095-2096.
  3. Rigatto C. Use of Oral Anticoagulation in the Management of Atrial Fibrillation in Patients with ESRD: Verdict 3. Clin J Am Soc Nephrol. 2016 Nov 7;11(11):2097.
  4. Keskar V, Sood MM. Use of Oral Anticoagulation in the Management of Atrial Fibrillation in Patients with ESRD: Con. Clin J Am Soc Nephrol. 2016 Nov 7;11(11):2085-2092.
  5. Bansal N. Use of Oral Anticoagulation for Patients with ESRD on Hemodialysis with Atrial Fibrillation: Verdict 1. Clin J Am Soc Nephrol. 2016 Nov 7;11(11):2093-2094.
  6. McCullough PA, Ball T, Cox KM, Assar MD. Use of Oral Anticoagulation in the Management of Atrial Fibrillation in Patients with ESRD: Pro. Clin J Am Soc Nephrol. 2016 Nov 7;11(11):2079-2084.
  7. http://www.kdigo.org/meetings_events/pdf/KDIGO%20CVD%20Controversy%20Rpt.pdf Accessed January 12, 2017.