Atrial fibrillation (AF) frequently complicates the management of chronic kidney disease, especially in patients with end-stage renal disease (ESRD). AF occurs in approximately one in five of the 650 000 patients with ESRD in the USA.1 ESRD confers increased risk for AF, while AF hastens progression to ESRD. The presence of chronic kidney disease in patients with AF is associated with an increased risk for ischaemic stroke independent of traditional risk factors. In addition, chronic kidney disease and particularly ESRD are associated with an increased risk of bleeding.

Little is understood about how to safely reduce the risk of thromboembolic events in patients with AF and ESRD. Prospective trials of AF have uniformly excluded patients with a glomerular filtration rate (GFR) <30 mL/hour. ESRD produces alterations in haemostasis that predispose patients to haemorrhagic (platelet α granule depletion, reduced endothelial cell adhesion molecule expression) and thrombotic (increased circulating fibrinogen) complications, limiting extrapolation of data from patients with normal renal function. Data on the net clinical effect of warfarin in patients with ESRD are limited to observational studies. Many experiences have suggested harm in the form of excess stroke and death, while others have suggested benefit (table 1).2–6 Reflecting uncertainty in the available body of evidence, Kidney Disease: Improving Global Outcomes (KDIGO) modified their 2011 consensus statement on cardiovascular disease to recommend against routine oral anticoagulation in dialysis patients with AF.1 In contrast, the most recent 2014 American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Rhythm Society guidelines on AF provide a grade IIa recommendation for use of warfarin in ESRD.