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Published on: February 28, 2012
Oral anticoagulation for stroke prevention in atrial fibrillation and advanced kidney disease
Ellen Linnea Freese Ballegaard1,2, Jonas Bjerring Olesen3, Anne-Lise Kamper1
1Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
Insights
Oral anticoagulation (OAC) in advanced chronic kidney disease patients with atrial fibrillation reduced thromboembolic events and death but increased major bleeding risk. This highlights a complex benefit-risk balance for these high-risk individuals.
Area of Science:
- Nephrology
- Cardiology
- Pharmacology
Background:
- The net benefit of oral anticoagulation (OAC) in patients with advanced chronic kidney disease (CKD) and atrial fibrillation (AF) is not well-established.
- Patients with an estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m2, including those on dialysis, represent a complex population for anticoagulation therapy.
Purpose of the Study:
- To evaluate the utilization, effectiveness, and safety of OAC in patients with advanced CKD and AF.
- To compare the one-year risks of thromboembolic events, major bleeding, and death between treated and untreated patients.
Main Methods:
- Retrospective cohort study using national Danish registers (2010-2022).
- Inclusion criteria: diagnosed AF and eGFR <30 mL/min/1.73 m2.
- OAC initiation identified by prescription redemption; outcomes assessed one year post-initiation.
Main Results:
- 3208 patients included (mean age 80 years, 20.9% on dialysis).
- OAC initiated in 42.9% of patients, using either vitamin K antagonists or direct oral anticoagulants.
- Compared to no OAC, anticoagulation was associated with a lower one-year risk of thromboembolic events (3.6% vs 4.8%) and death (29.6% vs 36.3%), but a higher risk of major bleeding (10.5% vs 7.6%).
Conclusions:
- In patients with advanced CKD and AF, OAC is associated with a reduced one-year risk of thromboembolic events and death.
- This benefit is counterbalanced by an increased one-year risk of major bleeding.
- The findings underscore the complex risk-benefit profile of OAC in this specific patient group.
Background:
The net benefit of oral anticoagulation (OAC) with vitamin K antagonists or direct oral anticoagulants in patients with advanced chronic kidney disease and atrial fibrillation remains uncertain.
Objectives:
We examined the use, efficacy, and safety of OAC in patients with estimated glomerular filtration rate (eGFR) of <30 mL/min/1.73 m2 (including dialysis-treated patients) and atrial fibrillation.
Methods:
In a retrospective cohort study, patients diagnosed with atrial fibrillation and eGFR of <30 mL/min/1.73 m2 were identified in national Danish registers between 2010 and 2022. Initiation of OAC was identified based on redemption of a relevant prescription. One-year risks of thromboembolic event, major bleeding, and death associated with OAC and no treatment were computed and standardized to the distribution of risk factors in the sample based on hazards determined in multiple Cox regression models adjusted for age and sex.
Results:
A total of 3208 patients were included (mean age 80 years, 52.8% males, 20.9% chronic dialysis). OAC was initiated in 1375 (42.9%) patients, of whom 48.1% were vitamin K antagonists and 51.9% were direct oral anticoagulants. One-year risks in nontreated and anticoagulated patients were 4.8% (95% CI, 3.8%-5.7%) and 3.6% (95% CI, 2.8%-4.6%; P = .028) for thromboembolic event, 7.6% (95% CI, 6.6%-8.7%) and 10.5% (95% CI, 9.3%-12.1%; P < .001) for major bleeding, and 36.3% (95% CI, 34.2%-38.3%) and 29.6% (95% CI, 27.6%-31.6%; P < .001) for death, respectively.
Conclusion:
In a retrospective study on patients with advanced chronic kidney disease and atrial fibrillation, OAC was associated with overall decreased 1-year risk of thromboembolic event and death offset by increased 1-year risk of major bleeding.
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