Anticoagulation Strategies for Atrial Fibrillation in CKD Stage G5 and Dialysis Patients: An Updated Scoping Review

Area of Science:

• Nephrology
• Cardiology
• Pharmacology

Background:

• Clinical trials for direct oral anticoagulants (DOACs) often exclude patients with advanced chronic kidney disease (CKD).
• This exclusion creates uncertainty about DOACs' safety and efficacy compared to warfarin in this high-risk population.
• Atrial fibrillation (AF) patients with CK G5 or on dialysis require clear guidance on anticoagulation therapy.

Purpose of the Study:

• To evaluate the effectiveness and safety of DOACs versus warfarin and no anticoagulation in AF patients with advanced CKD.
• To address the gap in knowledge regarding anticoagulation strategies for patients with CKD stage G5 or on dialysis.

Main Methods:

• A six-stage scoping review framework was employed, adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
• An exhaustive literature search was conducted across four databases for studies published up to August 2024.
• Data extraction and independent qualitative and quantitative analyses were performed on 33 included studies.

Main Results:

• DOACs, particularly apixaban, were linked to a 20-30% reduction in major bleeding risk compared to warfarin.
• Stroke incidence was similar between DOACs and vitamin K antagonists (VKAs), with apixaban demonstrating superior stroke prevention in severe CKD.
• Observational data indicated slightly lower mortality rates with DOACs, including fewer cardiovascular deaths, compared to VKAs.

Conclusions:

• DOACs, especially apixaban and rivaroxaban, offer a favorable safety profile over warfarin for AF patients with advanced CKD.
• Evidence remains inconsistent regarding the balance between thromboembolic prevention and bleeding risks in this population.
• Future research should concentrate on optimizing DOAC dosing strategies and assessing long-term outcomes.