From the Guidelines
The anticoagulant of choice for patients on dialysis is apixaban, with a recommended dose of 2.5 mg twice daily, as it has been shown to have a lower risk of major bleeding compared to warfarin in observational studies 1. When considering anticoagulation therapy for patients on dialysis, it is essential to weigh the risks and benefits of different options.
- Unfractionated heparin (UFH) is commonly used for hemodialysis sessions, but its use is limited to the duration of the session.
- Warfarin is often used for long-term anticoagulation in dialysis patients with conditions like atrial fibrillation, but it requires careful INR monitoring and has a higher risk of bleeding compared to apixaban.
- Direct oral anticoagulants (DOACs) like apixaban have been shown to be effective and safe in patients with chronic kidney disease, and apixaban 2.5 mg twice daily has been found to have plasma levels similar to those in patients with normal renal function 1. The choice of anticoagulant should always be individualized based on the patient's bleeding risk, comorbidities, and specific dialysis requirements.
- A recent systematic review and meta-analysis found that NOACs, including apixaban, had a trend toward better thromboembolic and bleeding outcomes compared to vitamin K antagonists in patients with chronic kidney disease 1.
- However, it is crucial to note that the use of NOACs in patients on dialysis is still being studied, and the results of ongoing trials, such as RENAL-AF and AXADIA, are eagerly awaited to confirm the safety and efficacy of apixaban in this population 1.
- Until then, apixaban 2.5 mg twice daily remains a reasonable choice for anticoagulation in patients on dialysis, given its favorable risk-benefit profile compared to warfarin.
From the FDA Drug Label
Patients with End-Stage Renal Disease on Dialysis Clinical efficacy and safety studies with apixaban did not enroll patients with end-stage renal disease (ESRD) on dialysis. In patients with ESRD maintained on intermittent hemodialysis, administration of apixaban at the usually recommended dose [see Dosage and Administration (2. 1)] will result in concentrations of apixaban and pharmacodynamic activity similar to those observed in the ARISTOTLE study [see Clinical Pharmacology (12. 3)]. It is not known whether these concentrations will lead to similar stroke reduction and bleeding risk in patients with ESRD on dialysis as was seen in ARISTOTLE
The FDA drug label does not answer the question.
From the Research
Anticoagulant Options for Patients on Dialysis
- Unfractionated heparin (UFH) is the most commonly used anticoagulant in the United States for patients on dialysis, due to its low cost and staff familiarity 2, 3.
- However, UFH has variable pharmacodynamics and can cause bleeding, heparin-induced thrombocytopenia, and other complications 2, 4.
- Low-molecular-weight heparins (LMWHs) have been developed to improve reliability and have been shown to be effective in preventing extracorporeal circuit clotting, with fewer bleeding episodes and less heparin-induced thrombocytopenia than UFH 4, 5, 6.
- LMWHs have become the anticoagulant of choice in Europe for routine outpatient hemodialysis sessions, due to their ease of administration and reliability of clinical effect 4, 6.
- Alternative anticoagulants, such as direct thrombin inhibitors and heparinoids, are available for patients who are allergic to heparin or have heparin-induced thrombocytopenia 5.
- Regional anticoagulants, such as citrate infusions, can also be used to limit anticoagulation to the extracorporeal circuit 5.
- Anticoagulant-free hemodialysis is also a potential option, but may require the use of specialized dialyzers or equipment 2, 3.