We thank Huang et al. for their interest in our review.1 Dialysis patients in all CHA2DS2-VASc risk strata have a higher risk of stroke,2 but this validated score still appears to be the most accurate in predicting ischemic stroke and warfarin may be considered especially in high risk patients.3 This must be balanced with bleeding risk factors, but the net benefit is generally positive, especially with well managed warfarin.
Atrial fibrillation patients with end-stage renal disease (ESRD) have been excluded from trials of nonvitamin K antagonist oral anticoagulants and thus any recommendations from regulatory authorities are not supported by trial evidence. Warfarin may reduce the risk of ischemic stroke, although this is controversial,4 since major bleeding is frequent in ESRD. A major caveat is that previous studies variably consider the quality of anticoagulation control, as reflected by time in therapeutic range, and a high therapeutic range is associated with good outcomes in ESRD.
Hence, an individualized patient approach is required, although the benefits of stroke and mortality reduction usually outweigh the risks of serious bleeds.5 For instance, if a stable ESRD patient can maintain a therapeutic range ≥ 70%–which is hard to achieve but not impossible–and has significant risk factors for stroke (CHA2DS2-VASc ≥ 2) and a low bleeding risk (HAS-BLED score <3), warfarin may be considered after an in-depth risk/benefit discussion.6 Patients on peritoneal dialysis and hemodialysis should be analyzed separately because of the potential differences in drug removal in these renal replacement modalities.
CONFLICTS OF INTERESTG.Y.H. Lip is a consultant for Bayer/Janssen, BMS/Pfizer, Medtronic, Boehringer Ingelheim, Novartis, Verseon and Daiichi-Sankyo and a speaker for Bayer, BMS/Pfizer, Medtronic, Boehringer Ingelheim, and Daiichi-Sankyo; he declares not directly receiving any personal fees derived from these activities.