# N14 — The Anticoagulated Patient at the Chair

N14 — The Anticoagulated Patient at the Chair FRONT Front · at the chair

**When:** every treatment for a patient on apixaban (Eliquis), warfarin (Coumadin), rivaroxaban (Xarelto), or another blood thinner. The written order and your unit protocol govern.

### Do this

1.  **Confirm the drug, the dose, and the last dose** every treatment (“Did you take your blood thinner last night and this morning?”). Apixaban dose: per your nephrologist’s order / unit protocol.
2.  **Heparin:** per your nephrologist’s order / unit protocol. Don’t assume the standard bolus and infusion apply; if the order doesn’t address the blood thinner, ask before you start.
3.  **If a heparin-free run is ordered,** watch for dark streaks in the dialyzer, clot in the venous chamber, or rising venous or transmembrane pressure \[[3](https://urinenephrology.org/mastery/maintenance-hd/nursing/N14-Anticoagulated-Patient-at-the-Chair.html#n14-ref-3)\].
4.  **Needle sites:** firm pressure without stopping flow (you should still feel the thrill). **Time it and write down the minutes every session** \[[12](https://urinenephrology.org/mastery/maintenance-hd/nursing/N14-Anticoagulated-Patient-at-the-Chair.html#n14-ref-12)\].
5.  **Warfarin:** draw the INR with pre-dialysis labs as ordered. Call when the INR is outside the range in the patient’s order \[[8](https://urinenephrology.org/mastery/maintenance-hd/nursing/N14-Anticoagulated-Patient-at-the-Chair.html#n14-ref-8)\].
6.  **Ask every week:** black or tarry stools, blood in stool or urine, vomiting blood, nosebleeds, new bruising, any fall, any bump to the head \[[2](https://urinenephrology.org/mastery/maintenance-hd/nursing/N14-Anticoagulated-Patient-at-the-Chair.html#n14-ref-2)\]\[[9](https://urinenephrology.org/mastery/maintenance-hd/nursing/N14-Anticoagulated-Patient-at-the-Chair.html#n14-ref-9)\].
7.  **Apixaban on dialysis days:** usual times — no hold before treatment, no extra dose after \[[5](https://urinenephrology.org/mastery/maintenance-hd/nursing/N14-Anticoagulated-Patient-at-the-Chair.html#n14-ref-5)\]\[[6](https://urinenephrology.org/mastery/maintenance-hd/nursing/N14-Anticoagulated-Patient-at-the-Chair.html#n14-ref-6)\]. Missed dose: the label says take it as soon as possible that day; never double \[[7](https://urinenephrology.org/mastery/maintenance-hd/nursing/N14-Anticoagulated-Patient-at-the-Chair.html#n14-ref-7)\].
8.  **Before a procedure or catheter change:** tell the nephrologist the drug and the last dose. Cannulation needs no hold.
9.  **Before the patient leaves:** steady, not lightheaded ([N5: Intradialytic Hypotension: Chair-Side Response](https://urinenephrology.org/mastery/maintenance-hd/nursing/N5-Intradialytic-Hypotension-Response.html)).

### Call the nephrologist when

- **Now** (and follow your unit emergency plan, [N12: Chair-Side Emergencies](https://urinenephrology.org/mastery/maintenance-hd/nursing/N12-Chair-Side-Emergencies.html)): a fall with a head strike; new headache, confusion, vomiting, weakness, slurred speech, or vision change; vomiting blood; black or bloody stools; bleeding that won’t stop with firm pressure; a fast-growing access hematoma.
- **Same day:** the INR is outside the range in the patient’s order — **now** if the patient is bleeding.
- **Same day:** the circuit clotted on a heparin-free run; blood in the urine; an unexplained hemoglobin drop ([N10: Anemia Protocol: ESA and Iron Hold/Report Rules](https://urinenephrology.org/mastery/maintenance-hd/nursing/N10-Anemia-Protocol-Nursing.html)).
- **Same day:** new aspirin, clopidogrel, prasugrel, ticagrelor, NSAID, “-azole” antifungal, ritonavir, rifampin, carbamazepine, phenytoin, or St. John’s wort \[[7](https://urinenephrology.org/mastery/maintenance-hd/nursing/N14-Anticoagulated-Patient-at-the-Chair.html#n14-ref-7)\]; taking both warfarin and apixaban; a dose that doesn’t match the order; the drug stopped or unaffordable.
- **At rounds:** needle-site bleeding longer than the patient’s usual for **three sessions in a row** \[[12](https://urinenephrology.org/mastery/maintenance-hd/nursing/N14-Anticoagulated-Patient-at-the-Chair.html#n14-ref-12)\]; a fall without a head strike.
- AF patients: see [N1: Potassium Bath Selection](https://urinenephrology.org/mastery/maintenance-hd/nursing/N1-Potassium-Bath-Selection.html) for potassium call rules.

### Don’t

- Don’t give a heparin bolus to a patient on a blood thinner unless it is ordered.
- Don’t stop, skip, hold, or double a dose on your own — or tell the patient to \[[7](https://urinenephrology.org/mastery/maintenance-hd/nursing/N14-Anticoagulated-Patient-at-the-Chair.html#n14-ref-7)\].
- Don’t blame all prolonged needle-site bleeding on the drug. Three sessions in a row can mean the access is narrowing ([Examining and Cannulating the AVF and AVG](https://urinenephrology.org/mastery/maintenance-hd/avf-avg-exam-cannulation.html)).
- Don’t give vitamin K or a reversal drug without an order.
- Don’t let a patient leave after a head strike without talking to the nephrologist.
- Don’t treat a fall as a reason to stop the blood thinner — report it; the physician decides \[[10](https://urinenephrology.org/mastery/maintenance-hd/nursing/N14-Anticoagulated-Patient-at-the-Chair.html#n14-ref-10)\].

N14 — The Anticoagulated Patient at the Chair BACK Back · why, and the evidence

### Why

1.  In RENAL-AF, 26–32% of dialysis patients on apixaban or warfarin had a major or clinically relevant bleed within a year, versus about 3% with a stroke or embolism \[[1](https://urinenephrology.org/mastery/maintenance-hd/nursing/N14-Anticoagulated-Patient-at-the-Chair.html#n14-ref-1)\]. GI bleeding is the most common major bleed on dialysis (2.3 per 100 patient-years) \[[2](https://urinenephrology.org/mastery/maintenance-hd/nursing/N14-Anticoagulated-Patient-at-the-Chair.html#n14-ref-2)\].
2.  In a randomized crossover trial, 10 patients on oral anticoagulants had 40 treatments with and without added circuit anticoagulation; none ended early \[[3](https://urinenephrology.org/mastery/maintenance-hd/nursing/N14-Anticoagulated-Patient-at-the-Chair.html#n14-ref-3)\]. The UK Kidney Association suggests a heparin-free start (grade 2D) \[[4](https://urinenephrology.org/mastery/maintenance-hd/nursing/N14-Anticoagulated-Patient-at-the-Chair.html#n14-ref-4)\]. The trial predates wide apixaban use — so watch the circuit.
3.  A dialysis session removes about 4% of apixaban, and levels don’t depend on dose timing \[[5](https://urinenephrology.org/mastery/maintenance-hd/nursing/N14-Anticoagulated-Patient-at-the-Chair.html#n14-ref-5)\]\[[6](https://urinenephrology.org/mastery/maintenance-hd/nursing/N14-Anticoagulated-Patient-at-the-Chair.html#n14-ref-6)\]. Dose is debated: the label gives 5 mg twice daily unless age 80 or older or weight 60 kg or less \[[7](https://urinenephrology.org/mastery/maintenance-hd/nursing/N14-Anticoagulated-Patient-at-the-Chair.html#n14-ref-7)\]; steady-state data show 2.5 mg twice daily on dialysis matches 5 mg exposure with normal kidneys \[[5](https://urinenephrology.org/mastery/maintenance-hd/nursing/N14-Anticoagulated-Patient-at-the-Chair.html#n14-ref-5)\]. Even a 48–72-hour pre-procedure hold may be too short \[[6](https://urinenephrology.org/mastery/maintenance-hd/nursing/N14-Anticoagulated-Patient-at-the-Chair.html#n14-ref-6)\].
4.  In RENAL-AF, warfarin patients were in the target INR range only 44% of the time \[[1](https://urinenephrology.org/mastery/maintenance-hd/nursing/N14-Anticoagulated-Patient-at-the-Chair.html#n14-ref-1)\], and in a US dialysis cohort, patients whose INR was not checked in the unit had the highest stroke risk \[[8](https://urinenephrology.org/mastery/maintenance-hd/nursing/N14-Anticoagulated-Patient-at-the-Chair.html#n14-ref-8)\]. The UK Kidney Association advises reassessing warfarin when time in range falls below 65% \[[4](https://urinenephrology.org/mastery/maintenance-hd/nursing/N14-Anticoagulated-Patient-at-the-Chair.html#n14-ref-4)\].
5.  Dialysis patients 65 and older fell 1.6 times per person-year; 19% of falls caused injury \[[9](https://urinenephrology.org/mastery/maintenance-hd/nursing/N14-Anticoagulated-Patient-at-the-Chair.html#n14-ref-9)\]. Fall risk alone did not change the best stroke-prevention choice \[[10](https://urinenephrology.org/mastery/maintenance-hd/nursing/N14-Anticoagulated-Patient-at-the-Chair.html#n14-ref-10)\], but 1-year mortality after a spontaneous subdural hematoma on dialysis was 45.9% — 81% in those previously on an oral anticoagulant \[[11](https://urinenephrology.org/mastery/maintenance-hd/nursing/N14-Anticoagulated-Patient-at-the-Chair.html#n14-ref-11)\].

### Go deeper

- Mastery page: [Atrial fibrillation and anticoagulation in HD](https://urinenephrology.org/mastery/maintenance-hd/atrial-fibrillation-anticoagulation-hd.html)
- [All dialysis nursing reference cards](https://urinenephrology.org/mastery/maintenance-hd/nursing/index.html)

### References

1.  Pokorney SD, et al. Apixaban for patients with atrial fibrillation on hemodialysis: a multicenter randomized controlled trial (RENAL-AF). *Circulation.* 2022;146:1735-1745. [PubMed 36335914](https://pubmed.ncbi.nlm.nih.gov/36335914/)
2.  Coyle CR, et al. Major bleeding rates in an international cohort of patients with end-stage kidney disease. *Kidney Int Rep.* 2024;9:2814-2818. [PubMed 39291210](https://pubmed.ncbi.nlm.nih.gov/39291210/)
3.  Krummel T, et al. Haemodialysis in patients treated with oral anticoagulant: should we heparinize? *Nephrol Dial Transplant.* 2014;29:906-913. [PubMed 24459138](https://pubmed.ncbi.nlm.nih.gov/24459138/)
4.  UK Kidney Association. Clinical practice guideline: anticoagulation for atrial fibrillation in adults with advanced kidney disease. September 2025. [ukkidney.org](https://www.ukkidney.org/sites/default/files/documents/FINAL%20version%20Anticoagulants%20in%20Advanced%20CKD%20NVAF%20guide_Oct2025.pdf)
5.  Mavrakanas TA, et al. Apixaban pharmacokinetics at steady state in hemodialysis patients. *J Am Soc Nephrol.* 2017;28:2241-2248. [PubMed 28302754](https://pubmed.ncbi.nlm.nih.gov/28302754/)
6.  Konecki C, et al. Population pharmacokinetic modelling of apixaban in end-stage kidney disease patients with atrial fibrillation receiving haemodialysis. *Clin Pharmacokinet.* 2025;64:307-321. [PubMed 39853633](https://pubmed.ncbi.nlm.nih.gov/39853633/)
7.  ELIQUIS (apixaban) prescribing information. Bristol-Myers Squibb; DailyMed label, May 2025. [dailymed.nlm.nih.gov](https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=e9481622-7cc6-418a-acb6-c5450daae9b0)
8.  Chan KE, et al. Warfarin use associates with increased risk for stroke in hemodialysis patients with atrial fibrillation. *J Am Soc Nephrol.* 2009;20:2223-2233. [PubMed 19713308](https://pubmed.ncbi.nlm.nih.gov/19713308/)
9.  Cook WL, et al. Falls and fall-related injuries in older dialysis patients. *Clin J Am Soc Nephrol.* 2006;1:1197-1204. [PubMed 17699348](https://pubmed.ncbi.nlm.nih.gov/17699348/)
10. Man-Son-Hing M, et al. Choosing antithrombotic therapy for elderly patients with atrial fibrillation who are at risk for falls. *Arch Intern Med.* 1999;159:677-685. [PubMed 10218746](https://pubmed.ncbi.nlm.nih.gov/10218746/)
11. Yang L, et al. Nontraumatic subdural hematoma in patients on hemodialysis with end-stage kidney disease: a systematic review and pooled analysis. *Front Neurol.* 2023;14:1251652. [PubMed 37789893](https://pubmed.ncbi.nlm.nih.gov/37789893/)
12. Lok CE, et al. KDOQI clinical practice guideline for vascular access: 2019 update. *Am J Kidney Dis.* 2020;75(4 Suppl 2):S1-S164. [PubMed 32778223](https://pubmed.ncbi.nlm.nih.gov/32778223/)

Reviewed by Andrew Bland, MD, FACP, FAAP · v1.0 draft 2026-09-26. For education; the physician’s written order and the unit protocol always govern.


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[Website version](https://urinenephrology.org/mastery/maintenance-hd/nursing/N14-Anticoagulated-Patient-at-the-Chair.html) · Markdown synchronized October 3, 2026.