Anticoagulants, renal failure and atrial fibrillation

The prevalence of atrial fibrillation (AF) in patients with chronic renal failure (CRF) and end-stage renal disease (ESRD) is very high and also in this population AF is associated with an increased risk of stroke. Warfarin is the treatment of choice for AF to prevent thromboembolic events, but it has been reported that its use in CRF and hemodialysis (HD) patients is associated with an increased risk of bleeding compared with patients with normal renal function. Moreover, historical studies suggest that warfarin increases the incidence of both ischemic and hemorrhagic strokes in HD patients. However, a clear benefit:risk ratio against warfarin in patients with CRF or ESRD and AF has not been demonstrated. New oral anticoagulants, thrombin or factor Xa inhibitors, are now available. Patients with severe CRF (i.e., glomerular filtration rate < 30 mL/min) and with ESRD, however, were excluded from the trials that have established their efficacy and safety. The advent of new oral anticoagulants raises the important question if patients with severe CRF and ESRD should be excluded or not from this new therapeutic opportunity.