Which anticoagulants should be used for stroke prevention in non-valvular atrial fibrillation and severe chronic kidney disease?

Abstract

Non-valvular atrial fibrillation is common in patients with severe chronic kidney disease (CKD) and historically patients have been treated with vitamin K antagonists (VKA). However, these agents have questionable efficacy and are associated with increased bleeding risk. Non-vitamin K oral anticoagulants (NOAC) have advantages over VKA in early stage CKD. In this review, we sought to establish evidence for best practice in patients with severe CKD (creatinine clearance <30 ml/min including dialysis patients) and nonvalvular atrial fibrillation. Registry studies have shown that the relative risk of stroke in untreated atrial fibrillation in dialysis patients is lower than in patients in the general population, but VKA are associated with increased haemorrhagic stroke in this high-risk population. A large meta-analysis of dialysis patients found no benefit of VKA in reducing stroke, but an increased bleeding risk. However, studies from Scandinavia have emphasized that risk of VKA are mitigated by increasing the time in anticoagulant therapeutic range (TTR). The consensus from the Kidney Disease: Improving Global Outcomes conference on arrhythmia in CKD was that if dialysis patients required OAC for atrial fibrillation then apixaban could be considered in preference to VKA. Best practice prophylaxis against stroke risk in dialysis patients with atrial fibrillation is still an area of uncertainty. If OAC is indicated because of high risk, then treatment options include VKA with careful attention to increased TTR, or reduced dose apixaban, which would be off label in Europe. No RCT evidence currently exists to guide therapy, but RCTS of apixaban versus VKA in dialysis patients are currently underway.