Target INR Range for Patients with Atrial Fibrillation on Dialysis

Anticoagulation Recommendations for A-fib Patients on Dialysis

The American College of Cardiology recommends warfarin with a target INR of 2.0 to 3.0 for patients with nonvalvular atrial fibrillation who have end-stage chronic kidney disease (CKD) or are on hemodialysis with a CHA₂DS₂-VASc score of 2 or greater 1, 2, 3
Warfarin remains the anticoagulant of choice for patients with atrial fibrillation who are on dialysis, with a target INR of 2.0 to 3.0, supported by Class IIa, Level of Evidence B guidance from the American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) 1, 2, 4
Direct oral anticoagulants (DOACs) such as dabigatran and rivaroxaban are not recommended in patients with AF and end-stage CKD or on dialysis due to lack of evidence regarding the balance of risks and benefits (Class III: No Benefit) 1, 5

INR should be determined at least weekly during initiation of warfarin therapy, and once anticoagulation is stable, monitoring should occur at least monthly, according to the American College of Cardiology 3, 5

Patients with end-stage renal disease on dialysis have both increased risk of thromboembolism and increased risk of bleeding, and the CHA₂DS₂-VASc score should still be used to assess stroke risk in these patients 2, 4, 5
For patients with a CHA₂DS₂-VASc score of 2 or greater in men or 3 or greater in women who are on dialysis, warfarin anticoagulation is reasonable, as recommended by the American College of Cardiology 6

Apixaban might be considered in some dialysis patients according to more recent guidelines (2019 update), but warfarin remains the primary recommendation with the most evidence, as stated by the American College of Cardiology and the American Heart Association 6, 7
Dabigatran, rivaroxaban, and edoxaban are specifically not recommended in dialysis patients, due to lack of evidence, according to the American College of Cardiology 1, 6

Dialysis patients have an inherently higher risk of bleeding complications, making tight INR control particularly important, as noted by the American Heart Association 4
Regular reassessment of the need for and choice of anticoagulant therapy is recommended to reassess stroke and bleeding risks, according to the American College of Cardiology 3, 5