Which Anticoagulants Should Be Used for Stroke Prevention in Non-Valvular Atrial Fibrillation and Severe Chronic Kidney Disease?

Philip A. Kalra; Alexandru Burlacu; Charles J. Ferro; Adrian Covic


Curr Opin Nephrol Hypertens. 2018;27(6):420-425. 

In This Article

Risks Associated With Untreated Atrial Fibrillation in Severe Chronic Kidney Disease: Should Anticoagulation be Used at all?

Atrial fibrillation is highly prevalent in dialysis patients, with age and cardiovascular comorbidities key factors in the association. In a cross-sectional study of 626 haemodialysis patients in centres in Vienna, Konigsbrugge et al.[4] found an atrial fibrillation prevalence of 26.5% of which a third had permanent atrial fibrillation and almost 60% paroxysmal atrial fibrillation. The relative risk of stroke with untreated atrial fibrillation varies with level of renal function; the hazard ratio for women in the general population is 4.2, whereas Shih et al.[5] found a hazard ratio of 1.3 in a dialysis registry study of almost 6800 patients in Taiwan. These differences are thought to be due to the competing risk of death in advanced CKD, and also the increased risk of stroke in the absence of atrial fibrillation in this population. An increased risk of death is also recognized with atrial fibrillation in CKD. Winkelmayer et al.[6] found this increment to be 45% in US dialysis patients with atrial fibrillation compared to those without, and Bansal et al.[7] identified that incident atrial fibrillation independently increased mortality risk by 66% in over 81 000 patients with CKD in the Kaiser Permanente population, although only 9% of this population had CKD stage 4 or worse.

The case for anticoagulation for stroke prevention in atrial fibrillation is therefore strong in the general population and in patients with early stage CKD, but less clear for dialysis patients. The rationale for anticoagulation to reduce mortality in atrial fibrillation in advanced CKD is also less clear, as the risks of serious complications, particularly bleeding in dialysis patients, is also increased in this population. Consensus now suggests that the embolic (CHA2DS2VASC)[8] and bleeding (HASBLED)[9] risk scores should be considered on an individual basis before deciding upon anticoagulation for these patients.