Atrial fibrillation in CKD: balancing the risks and benefits of anticoagulation

Chronic kidney disease (CKD) and atrial fibrillation are common conditions that often coexist and are associated with increased risk of stroke. Despite the wealth of evidence for optimal management of atrial fibrillation in the general population, the role of anticoagulation with warfarin in individuals with CKD with atrial fibrillation is far less well defined. Current recommendations for anticoagulation in patients treated with dialysis and those with an earlier stage of CKD are based on clinical trials in the general atrial fibrillation population that have largely excluded individuals with CKD. Observational studies of anticoagulation in dialysis patients have produced conflicting results, mainly because of increased risk of bleeding. This, together with warfarin's potential adverse effects on ectopic/vascular calcification and progression of CKD, may result in negating the benefits associated with anticoagulation in the general population. With the recent emergence of novel oral anticoagulants, there is an urgent need for a better understanding of the complex inter-relationship among CKD, atrial fibrillation, stroke, and bleeding risk. This knowledge is paramount to optimize the potential benefits of treatment and minimize the potential harms in this very high-risk and growing population.