Patients with renal failure on dialysis are at increased risk for both bleeding and thrombotic events. All DOAC medications are renally cleared, increasing the risk for drug accumulation, supra- therapeutic drug levels, and bleeding events in patients with renal failure. Although overall data are limited in this population, a large retrospective study matched 2351 patients with AF on dialysis who took apixaban against 23172 taking warfarin and found a 28% lower rate of bleeding events in those taking apixaban.438 This finding supports the use of apixaban as an alternative choice for antico- agulation in patients with AF on dialysis. Knowledge Gaps and Future Research Optimal management strategies to reduce the risk of recurrent stroke in patients with AF have improved sub- stantially with support from large trial data; however, knowledge gaps remain, including: The minimal duration of AF that engenders signifi- cant stroke risk and benefit of oral anticoagulation beyond the bleeding risk remains unknown. Multiple studies reflecting the increased use of monitoring technologies are ongoing. The safety of discontinuing oral anticoagulation after surgical appendage closure remains uncertain. Small series of surgical technologies have demon- strated technical success, but the relevance to clini- cal need for oral anticoagulation remains unknown. Multiple transcatheter approaches to left atrial appendage closure are under investigation and will provide additional options for stroke risk reduction while minimizing risk of bleeding with long-term anticoagulation. For patients who have had AF followed by success- ful ablation, the need for continued anticoagulation is uncertain and continues to be studied. Patients with limited postoperative AF are at increased risk of recurrence; however, further research is needed to identify which patients would benefit from long-term anticoagulation. 