Whether oral anticoagulation provides a net clinical benefit in patients with kidney failure requiring hemodialysis (KF-HD) and atrial fibrillation (AF) remains unresolved despite decades of debate, resulting in considerable physician uncertainty and variation in clinical practice.1 Even so, in most published cohorts from across the globe fewer than one-third of KF-HD with AF receive any oral anticoagulant.2-4 Among treated patients, the use of direct oral anticoagulants (DOAC) has increased over time, although adoption rates differ across regions owing to variations in labeling and regulatory constraints.