Anticoagulation in Advanced Chronic Kidney Disease: Navigating Uncertainty

Advanced chronic kidney disease (CKD) is characterized by a complex hemostatic state in which thrombotic and bleeding risks coexist. As kidney function declines, balancing thrombotic protection against bleeding risk becomes increasingly challenging. Although atrial fibrillation is common and associated with a high stroke risk in advanced CKD, the net clinical benefit of anticoagulation remains uncertain because this population has been largely excluded from pivotal randomized trials. Existing risk scores incompletely capture CKD-specific and dynamic determinants of both thrombosis and bleeding. Observational data suggest potential advantages of apixaban over warfarin, whereas evidence for other agents remains limited. Recent randomized evidence has reinforced the difficulty of extrapolating antithrombotic strategies from the general cardiovascular population to advanced CKD. Future research should prioritize CKD-specific risk prediction, inclusion of advanced CKD populations in randomized trials, and safer anticoagulant strategies, including factor XI/XIa inhibitors.