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Atrial fibrillation ( AF ) is a frequent comorbid condition in patients with end‐stage renal disease on hemodialysis ( HD ) with a prevalence of up to 27%. The incidence rate of stroke in  AF  patients on  HD  is approximately 5%. The  AF ‐associated risk of stroke is a major clinical challenge because current evidence for anticoagulation in  HD  patients with  AF  is based on observational data. Results from these observational studies is largely contradictory because they do not show a clear benefit of vitamin K antagonists over no treatment in terms of stroke prevention, and they show an increased risk of hemorrhage associated with anticoagulation treatment in  HD  patients.  HD  patients were not included in randomized trials of the direct oral anticoagulants ( DOAC s), and therefore there is no evidence to support efficacy and safety of  DOAC s compared to vitamin K antagonists in  HD  patients. The pharmacological characteristics of  DOAC s are of particular interest in the  HD  setting. The factor Xa inhibitors rivaroxaban, apixaban, and edoxaban are not predominantly eliminated via the kidneys. The thrombin inhibitor dabigatran is 80% eliminated via the kidneys but is dialyzable due to its low protein binding. In this narrative review, we examine the current state of evidence regarding the prevalence of  AF  in patients on  HD , the associated risk of stroke, and the efficacy and safety of anticoagulation for stroke prevention in the  HD  setting. Further, based on the pharmacokinetic properties of  DOAC s, we discuss their potential use in patients on  HD  and ongoing randomized trials.

Atrial fibrillation in patients with end‐stage renal disease on hemodialysis: Magnitude of the problem and new approach to oral anticoagulation