Safety and efficacy of anticoagulant administration in people with atrial fibrillation and advanced chronic kidney disease.

INTRODUCTION

Advanced chronic kidney disease (CKD), defined as an estimated glomerular filtration rate < 30 ml/min/1.73 m2, significantly amplifies the challenges of managing atrial fibrillation (AF), highly prevalent in this population. People with advanced CKD besides increased cardiovascular risk are also at increased risk of both thromboembolic events and bleeding complications. Evidence regarding optimal anticoagulant use in this specific population remains limited, as most pivotal trials exclude people with advanced CKD, also those on maintenance dialysis.

AREAS COVERED: This review examines the safety and efficacy of anticoagulation strategies, namely vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) in people with AF and advanced CKD. It highlights the shortcomings of existing thromboembolism risk stratification tools and explores the off-target effects of anticoagulants. The literature search utilized PubMed, Embase, and Web of Science.

EXPERT OPINION: Some emerging data suggest that DOACs, particularly rivaroxaban and apixaban, may offer improved safety profiles compared to VKAs in advanced CKD, with comparable efficacy. Observational studies indicate a potential advantage of DOACs in preventing stroke or systemic embolism (SSE) over VKAs. Large clinical trials including a no-anticoagulation arm and validation of risk stratification tools specific to advanced CKD are urgently needed.