Anti-thrombotic therapy for atrial fibrillation in patients with chronic kidney disease: Current views

Chronic kidney disease (CKD) occurs in approximately one-third of patients with non-valvular atrial fibrillation (AF). The presence of CKD, particularly advanced CKD, confers increased risk of both thromboembolism and major bleeding in this group of patients who are already at risk for ischemic stroke and systemic embolism and at risk of bleeding due to anticoagulation. Studies assessing the effect of warfarin on risk of ischemic stroke, systemic embolism, and major bleeding have produced disparate results, particularly in patients with advanced CKD including those treated with hemodialysis. The direct oral anticoagulants (DOAC's) have been studied in patients with stage III (moderate) CKD and appear to be as effective or more effective (dabigatran 150 mg twice daily) than warfarin in preventing ischemic stroke or embolism in this group. Two of the DOAC's, apixaban and edoxaban, confer lower risk of major bleeding than warfarin with appropriate dose adjustments. Substantial gaps exist in our knowledge of anti-thrombotic therapy in patients with AF and CKD, primarily due to exclusion of patients with advanced CKD from randomized controlled trials comparing DOAC's with warfarin.