The Role of Direct Oral Anticoagulants in Advanced Chronic Kidney Disease – Questions and Future directions

Filip Ionescu ,Saima Mansuri

doi:10.33696/nephrology.1.003

Abstract

With the advent of the direct oral anticoagulants (DOACs), patients requiring anticoagulation for common conditions such as atrial fibrillation and venous thromboembolism no longer need to worry about dietary restrictions or regular monitoring of the international normalized ratio which complicated warfarin treatment. Switching from warfarin to apixaban, a DOAC, has been shown to improve patient satisfaction by reducing treatment burden [1]. The clotting factor Xa inhibitors (apixaban, rivaroxaban, and edoxaban) and the direct thrombin inhibitors (argatroban and dabigatran) have shown non-inferiority in preventing thromboembolic events and a superior safety profile in terms of bleeding in several trials when compared to warfarin [2-6]. Furthermore, apixaban and dabigatran have even shown superiority in preventing stroke or systemic embolism [3,6].

Highlights

With the advent of the direct oral anticoagulants (DOACs), patients requiring anticoagulation for common conditions such as atrial fibrillation and venous thromboembolism no longer need to worry about dietary restrictions or regular monitoring of the international normalized ratio which complicated warfarin treatment
There remains an important subgroup of patients who have been excluded from the initial DOAC trials: advanced chronic kidney disease (CKD stage 4-5) and hemodialysis (HD) patients
With one of the lowest percentages of renal clearance at 27% [22], apixaban may represent one of the safest choices in CKD patients and two retrospective studies have found a significantly lower bleeding risk with apixaban compared to warfarin in the CKD population, which was not demonstrated with other DOACs [23,24]