Stroke prevention in atrial fibrillation patients with chronic kidney disease

Chronic kidney disease (CKD) is prevalent in elderly patients with atrial fibrillation and is an independent risk factor for stroke. Warfarin anticoagulation is efficacious for stroke prevention in atrial fibrillation patients with moderate CKD (stage III, estimated glomerular filtration rate 30-59 mL/min), but recent observational studies have challenged its value for patients with end-stage renal disease requiring dialysis. The novel oral anticoagulants (i.e., dabigatran, apixaban, rivaroxaban) all undergo renal metabolism to varying degrees, and hence dosing, efficacy, and safety require special consideration in CKD patients. In randomized trials to date involving 11,169 patients with moderate CKD, the novel oral anticoagulants performed well, with similar efficacy and safety profiles as for non-CKD patients. For atrial fibrillation patients with stage III CKD, the available data are strongest for dabigatran 150 mg twice daily as superior to warfarin for stroke prevention and for apixaban as superior to warfarin regarding reduced major hemorrhage. Renal function should be monitored at least annually in patients receiving a novel oral anticoagulant, and more often in elderly patients and those with underlying CKD or comorbidities who are at special risk for dehydration and deterioration of renal function. Much remains to be learned about the optimal use of the novel oral anticoagulants in CKD patients; additional studies about optimal dosing of the novel oral anticoagulants and frequency of monitoring renal function in CKD patients with atrial fibrillation are needed. Anticoagulation options for hemodialysis patients require testing in randomized trials.