Systemic anticoagulation considerations in chronic kidney disease

Anticoagulation therapy is commonly required in patients with chronic kidney disease for treatment or prevention of thromboembolic disorders. Anticoagulant management plans can involve use of a single agent, or in some cases, a combination of agents to meet both short- and long-term goals. Systemic anticoagulation in the setting of renal insufficiency poses unique challenges secondary to renal failure-associated hypercoagulable conditions and increased risks for bleeding. Evidence supporting dosing regimens and monitoring approaches in the setting of severe renal impairment or hemodialysis is limited because this population is typically excluded in clinical trials. This review explores concepts of systemic anticoagulation in the chronic kidney disease setting with warfarin, unfractionated heparin, low-molecular-weight heparin, fondaparinux, direct thrombin inhibitors, and anticoagulants in advanced stages of development. Potential strategies for anticoagulant reversal are also briefly described.