From the Guidelines
Warfarin is the anticoagulant of choice for patients on dialysis, as it has been used with acceptable risks of hemorrhage in this population 1. When considering anticoagulation for patients on dialysis, particularly those with atrial fibrillation, the risk of stroke and bleeding must be carefully weighed.
Key Considerations
- For patients with end-stage chronic kidney disease (CKD) or on dialysis, warfarin (INR 2.0 to 3.0) or apixaban may be considered for oral anticoagulation 1.
- Direct thrombin inhibitors like dabigatran, or factor Xa inhibitors such as rivaroxaban or edoxaban, are not recommended for patients on dialysis due to the lack of evidence that their benefits exceed the risks 1.
Anticoagulation Management
- The choice of anticoagulant should be reevaluated at periodic intervals to reassess stroke and bleeding risks 1.
- For patients with atrial fibrillation and a CHA2DS2-VASc score of 2 or greater in men or 3 or greater in women who are on dialysis, warfarin or apixaban might be reasonable options 1.
- It is crucial to monitor INR levels closely in patients on warfarin to minimize the risk of bleeding complications.
- The use of direct oral anticoagulants (DOACs) in patients with end-stage renal disease requires careful consideration due to concerns about bioaccumulation and the potential for increased bleeding risk 1.
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) has been the most commonly used anticoagulant for patients on dialysis due to its low cost and staff familiarity 2.
- However, low-molecular-weight heparins (LMWHs) are being increasingly used as an alternative to UFH due to their ease of administration, reliability, and predictability of dosing 3.
- The choice of LMWH depends on the duration and frequency of dialysis sessions 3.
Alternative Anticoagulants
- For patients who are allergic to heparin or have heparin-induced thrombocytopenia, alternative anticoagulants such as direct thrombin inhibitors and heparinoids are available 3.
- Regional anticoagulants, such as prostanoids and nafamostat mesilate, can limit anticoagulation to the extracorporeal circuit, but are expensive 3.
- Citrate infusions can also be used as a regional anticoagulant, but add complexity to the procedure 3.
Comparison of Anticoagulant Strategies
- A systematic review found that LMWH may have uncertain effects on extracorporeal circuit thrombosis compared to UFH, and that major bleeding and minor bleeding were not adequately reported 4.
- Regional citrate anticoagulation may lower the risk of minor bleeding compared to UFH, but the effects on major bleeding and extracorporeal circuit thrombosis were not reported 4.
- The effects of other anticoagulant strategies, such as very LMWH, danaparoid, prostacyclin, direct thrombin inhibitors, factor XI inhibitors, or heparin-grafted membranes, were uncertain due to insufficient data 4.
Clinical Decision-Making
- The evidence supporting clinical decision-making for different forms of anticoagulant strategies for hemodialysis is of low and very low certainty, as available studies have not been designed to measure treatment effects on important clinical outcomes 4.
- Further research is needed to determine the most effective and safe anticoagulant strategy for patients on dialysis 4.