Dialysis and Renal Disease Management / Acute Kidney Injury Research · Journal article

Thromboembolic prophylaxis in kidney failure patients with atrial fibrillation undergoing hemodialysis: from risk stratification to decision making on anticoagulants or left atrial appendage closure. A position paper endorsed by the Italian Society of Nephrology

Journal of Nephrology · August 22, 2026

Expert Guidance Why this matters to you Expert discussion

A consensus or society position rather than new primary data.

AI Summary

This position paper reviews evidence on anticoagulation and left atrial appendage closure (LAAC) for thromboembolic prevention in hemodialysis patients with atrial fibrillation. No RCTs support oral anticoagulant therapy (OAC) in this population; observational studies suggest OAC carries increased bleeding risk, while LAAC shows non-inferior efficacy to OAC in preserved-kidney populations and similar or reduced thromboembolism and bleeding in kidney failure patients, though with higher peri-procedural complications.

What was studied

Journal article. Patients with kidney failure undergoing hemodialysis with atrial fibrillation.

Key findings

No RCTs demonstrate OAC protects against thromboembolic events in HD patients with AF Observational evidence suggests OAC is associated with increased bleeding risk in HD patients RCTs in preserved kidney function show LAAC is not inferior to OAC for efficacy and has greater safety

Safety

Specific effect sizes, hazard ratios, and confidence intervals for thromboembolism and bleeding outcomes not reported Observational evidence suggests OAC is associated with increased bleeding risk in HD patients

Who this may help

For clinicians managing hemodialysis patients with AF, this paper indicates that OAC efficacy is unproven and bleeding risk may be elevated, while LAAC shows promise as an alternative despite higher procedural risk. Decision-making should balance these trade-offs given the absence of robust trial evidence in this population.

Plain-language summary

This is a position paper endorsed by the Italian Society of Nephrology that synthesizes evidence on anticoagulation and LAAC in a specific population, providing recommendations where RCT evidence is absent.

Study design

As stated by the source record.

PopulationPatients with kidney failure undergoing hemodialysis with atrial fibrillation

Reported figures

Quoted from the source exactly as published.

Thromboembolic risk score threshold for OACCHA2DS2-VA ≥ 2

Clinical bottom line

Caveats

No RCTs of OAC or LAAC conducted in HD patients; evidence relies on observational studies and extrapolation from preserved-kidney populations
Specific effect sizes, hazard ratios, and confidence intervals for thromboembolism and bleeding outcomes not reported
LAAC peri-procedural complication rates quantified only as 'higher' without absolute figures
Position paper reflects Italian Society viewpoint; generalizability to other regions or healthcare systems not addressed

Evidence assessment

Graded across the dimensions that decide whether you should act, each from what the source actually supports. There is no single score, and where a dimension was not assessed it says so.

Study design

insufficient

Position paper; not a primary empirical study with a defined design.

Directness

strong

Addresses the specific clinical question: thromboembolic prophylaxis in HD patients with AF.

Consistency

limited

No RCTs in HD population; observational studies show mixed efficacy and safety signals.

Risk of bias

limited

Relies on observational evidence and RCTs in non-KF populations; evidence synthesis does not report bias assessment.

Sample adequacy

insufficient

Position paper; underlying studies not detailed. No primary sample size reported.

Source abstract

Atrial fibrillation (AF) is highly prevalent in patients with kidney failure (KF) who are undergoing hemodialysis (HD). All patients with AF and a thromboembolic risk score (CHA2DS2-VA) of two or more should be prescribed oral anticoagulant therapy (OAC), according to cardiology guidelines. However, there are no randomized controlled trials (RCTs) demonstrating that OAC protects against thromboembolic events in HD patients. Furthermore, evidence from observational studies is insufficient to demonstrate the benefits of OAC for preventing thromboembolism in HD patients with AF. Instead, it suggests that OAC is associated with an increased risk of bleeding in these patients. Left atrial appendage closure (LAAC) has been proposed as a means of preventing thromboembolic events in patients with AF. RCTs conducted in populations with preserved kidney function have demonstrated that the procedure is not inferior to OAC in terms of efficacy, and is associated with greater safety. Although no RCTs have tested the safety and efficacy of LAAC in KF patients undergoing HD, some observational studies suggest that LAAC has a similar efficacy profile in patients with and without KF. However, a higher incidence of peri-procedural complications has been reported. Observational studies comparing the efficacy and safety of LAAC with OAC in KF patients have shown a similar or reduced incidence of thromboembolism and bleeding in patients undergoing the procedure. The purpose of this Position Paper is to provide comprehensive, evidence-based information on the advantages and limitations of LAAC in KF patients with AF undergoing HD.

Follow from this

Taken from the source record, never inferred. Follow any of these and new work involving them reaches your briefing.

Pietro Manuel FerraroSimonetta GenovesiGiuseppe RegolistiStefano BianchiDialysis and Renal Disease ManagementAcute Kidney Injury ResearchGiuseppe BorianiLuca De Nicola