Atrial fibrillation (AF) is a frequent clinical complication in dialysis patients, and
warfarin therapy represents the most common approach for reducing the risk of
stroke in this population. However, current evidence based on observational studies, offer conflicting results, whereas no randomized controlled trials have been carried out so far. Additionally, many clinicians are wary of the possible role of
warfarin as
vascular calcification inducer and its potential to increase the high risk of
bleeding among patients on dialysis. Ideally the most promising
therapy would be based on direct inhibitors of
factor IIa or Xa; however, at the moment, none of these drugs can be safely prescribed in dialysis patients, because of their potentially dangerous accumulation, and the lack of sufficient experience with
apixaban or
rivaroxaban, two drugs showing a favorable pharmacokinetic profile in
end-stage renal disease. Hence, the use of
vitamin K inhibitors is currently the only pharmacological option for
stroke prevention in dialysis patients with
atrial fibrillation, leaving the clinicians in a management conundrum.This review discusses the trade-offs implicated in
warfarin use for this population, the promises of newly developed drugs, the role of dialysis as
atrial fibrillation trigger, as well as potential non-pharmacological management options suitable in selected clinical situations.