Oral Anticoagulation Use in Individuals With Atrial Fibrillation and Chronic Kidney Disease: A Review

Abstract

Atrial fibrillation (AF) is highly prevalent in patients with chronic kidney (CKD). It is associated with an increased risk of stroke, which increases as kidney function declines. In the general population and in those with a moderate degree of CKD (creatinine clearance 30-50 ml/min) the use of oral anticoagulation to decrease the risk of stroke has been the standard of care based on a favourable risk-benefit profile that had been established in seminal randomized control trials. However, evidence for the use of oral anticoagulants for stroke prevention is less clear in patients with severe CKD (creatinine clearance <30 ml/min) and in those receiving maintenance dialysis as they had been excluded from such large randomized control trials. Nevertheless, the direct oral anticoagulants (DOACs) have invariably usurped vitamin K antagonists as the preferred choice for oral anticoagulation among patients with AF, across all strata of CKD, based on their well-defined safety and efficacy, and multiple pharmacokinetic benefits (e.g.less drug-drug interactions). This review will summarize the current literature on the role of oral anticoagulation in the management of AF among patients with CKD and highlight current deficiencies in the evidence-base and how to overcome them.