Atrial fibrillation and chronic kidney disease: struggling through thick and thin

The prevalence of atrial fibrillation and the risk of stroke display an age-related increase in the chronic kidney disease (CKD) population. Evidence from large randomized controlled trials conducted in the general population supports the use of anticoagulation to reduce the risk of stroke in the setting of non-valvular atrial fibrillation. However, data in the non-dialysis-dependent and dialysis-dependent CKD populations are limited largely to observational studies, which demonstrate conflicting results regarding the risk-benefit profile of anticoagulation. The paradoxical increase in bleeding and thromboembolism that is observed in CKD further complicates decision-making on the use of anticoagulation. Several observational studies suggest an increased risk of bleeding that parallels the decline in renal function, with the highest rates of bleeding seen in the dialysis-dependent population, whereas other studies have not demonstrated any appreciable increase in bleeding risks with anticoagulation. Bleeding rates are largely driven by increased rates of gastrointestinal bleeding with anticoagulation, with minimal contribution of intra-cranial bleeding. Similarly, several studies have suggested lower rates of ischemic stroke and systemic thromboembolism with anticoagulation in people with CKD, whereas other studies have demonstrated no difference in rates of ischemic stroke. Given the paucity of high-quality evidence, and the high prevalence of atrial fibrillation in people with CKD, large randomized control trials are needed to provide recommendations for anticoagulation in this setting.