Abstract
Background/Objectives Patients receiving haemodialysis have multiple specific physiological and pharmacological considerations. The evidence to guide choices regarding anticoagulation for stroke prophylaxis in atrial fibrillation is one such area. The role for direct oral anticoagulants is increasingly being discussed.
Methods A case is discussed of a patient who had an ischaemic stroke, with a new diagnosis of atrial fibrillation, who has a past medical history of chronic kidney disease requiring dialysis.The evidence pertaining to this situation is reviewed.
Results A 57-year-old female patient presented with a left facial droop and left arm weakness and was subsequently diagnosed with a right middle cerebral artery ischaemic stroke. Her past medical history includes chronic kidney disease on haemodialysis (currently via permacath), and type 2 diabetes mellitus. Computed tomography demonstrated significant atherosclerotic disease both intracranially and extracranially, although without significant large vessel stenoses. Telemetry subsequently revealed a new diagnosis of atrial fibrillation. Additionally, she was being planned for two future operations: a fistuloplasty for her right brachiocephalic arteriovenous fistula (high venous pressures during dialysis due to proximal narrowing of the draining vein), and a left eye cataract phacoemulsification. Careful consideration was given to antithrombotic options. Following review of the evidence, she was commenced on apixaban 2.5mg twice per day.
Conclusion With the currently available evidence, anticoagulation decisions for patients requiring dialysis necessitates a carefully considered, individualised approach. The available evidence is useful but leaves significant gaps that could be gainfully addressed by future studies.
