Abstract
Over the past few decades, a series of innovative medicines have been developed in order to optimize anticoagulation therapy for atrial fibrillation (AF). As a result, a number of nonvitamin K antagonist oral anticoagulants (NOAC) that directly target the enzymatic activity of factor II and factor Xa have been successfully licensed providing a more predictable effect and better safety profile compared to conventional anticoagulants (heparins and vitamin K antagonists (VKAs)). However, comparative efficacy and safety data is limited in patients with advanced chronic kidney disease (i.e., CKD stage 4/5 and end stage renal disease) because patients with estimated glomerular filtration rate (eGFR) < 30 mL/min/1.73 m2 were actively excluded from landmark trials, thus representing a major clinical limitation for the currently available agents. However, the renal function of AF patients can be altered over time. On the other hand, patients with CKD have an increased risk of developing AF. This review article will provide an overview of current concepts and recent evidence guiding the clinical use of NOACs in patients with CKD requiring chronic anticoagulation, and the associated risks and benefits of treatment in this specific patient population.
Highlights
Ando et al, conducted a subgroup analysis of the patients with atrial fibrillation (AF) and moderate Chronic kidney disease (CKD) enrolled in the abovementioned trials and concluded that nonvitamin K antagonist oral anticoagulants (NOAC) showed lower incidence of both the ischemic endpoint and the major bleeding compared to warfarin [33]
According to Siontis and colleagues there was no difference in the risk of stroke and systemic thromboembolism between apixaban and warfarin (HR, 0.88; 95% CI, 0.69–1.12; p = 0.29), but apixaban was associated with a significantly lower risk of major bleeding (HR, 0.72; 95% CI, 0.59–0.87; p < 0.001)
In contrast the Canadian Cardiovascular Society (CCS) updated guidelines from 2020 suggest that warfarin is recommended with estimated glomerular filtration rate (eGFR) 15–30 mL/min and not on dialysis, but patients with AF receiving dialysis should not be prescribed oral anticoagulation or aspirin for stroke prevention [53,54]
Summary
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. The traditional cardiovascular risk factors, i.e., which is important because these patients are more likely to die of an acute cardiovascular age, hypertension, obesity, diabetes mellitus, coronary artery disease, heart failure, and event (such as sudden cardiac death or myocardial infarction) rather than to develop endsmoking are shared predisposing factors for AF and CKD. Both CKD and AF serve as stage renal disease (ESRD) [14,15]. Altered pharmacokinetics are leading to a massive challenge in the management of CKD patients in regard to oral anticoagulant treatment [28]
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