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Anticoagulants in atrial fibrillation patients with chronic kidney disease

Robert G Hart1, John W Eikelboom, Alistair J Ingram

  • 1Division of Neurology, Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4L8, Canada. robert.hart@phri.ca

Nature Reviews. Nephrology
|July 25, 2012
PubMed

Insights

Novel oral anticoagulants offer effective stroke prevention for atrial fibrillation patients with chronic kidney disease (CKD). These agents demonstrate comparable efficacy and safety to warfarin, with improved intracranial hemorrhage profiles, though dose adjustments are necessary for CKD patients.

Area of Science:

  • Nephrology
  • Cardiology
  • Pharmacology

Background:

  • Atrial fibrillation (AF) is a significant cause of stroke, particularly in patients with chronic kidney disease (CKD).
  • Stage 3 CKD is an independent risk factor for stroke in AF patients.
  • Warfarin's efficacy in AF patients with stage 3 CKD is established, but its utility in end-stage renal disease is debated.

Purpose of the Study:

  • To review the efficacy and safety of novel oral anticoagulants (NOACs) in patients with atrial fibrillation and chronic kidney disease.
  • To compare NOACs with warfarin for stroke prevention in this patient population.
  • To highlight considerations for NOAC dosing, efficacy, and safety in patients with varying degrees of renal impairment.

Main Methods:

  • Review of randomized trials and observational studies on NOACs (dabigatran, apixaban, rivaroxaban) in patients with atrial fibrillation and CKD.
  • Analysis of data regarding stroke prevention, bleeding risks (especially intracranial hemorrhage), and renal clearance.
  • Evaluation of dosing modifications and perioperative management in CKD patients.

Main Results:

  • NOACs are at least as efficacious as warfarin for stroke prevention in AF patients with stage 3 CKD.
  • NOACs demonstrate a reduced risk of intracranial hemorrhage compared to warfarin.
  • NOACs have shown similar efficacy and safety profiles in randomized trials for patients with stage 3 CKD as in those without CKD, necessitating dose adjustments.
  • Longer discontinuation periods for NOACs are required before elective surgery in CKD patients due to reduced renal clearance.

Conclusions:

  • NOACs are attractive anticoagulation options for atrial fibrillation patients with CKD.
  • Dosing, efficacy, and safety of NOACs require careful consideration in CKD patients due to varying renal clearance.
  • NOACs are likely to replace warfarin for stroke prevention in AF patients with CKD in the future, despite the need for further research on optimal use.

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