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


No RCT data are available to provide definitive safety and efficacy data comparing NOAC with VKA in patients with severe CKD. However, on the basis of observational and registry studies, the very limited pharmacokinetic studies with NOAC in dialysis patients, and the foregoing review of the recent literature, we feel that the following pragmatic approach is justified (summarized in Figure 1):

Figure 1.

Pragmatic approach to prophylaxis of stroke risk in patients with severe chronic kidney disease.

  1. Assess the embolic risk (CHA2DS2VASC) of the patient with severe CKD and atrial fibrillation; if this is intermediate or greater then consider anticoagulant therapy.

  2. If VKA are to be used then maintain TTR more than 70% with careful monitoring

  3. CrCl 15–30 ml/min: VKA or NOAC (apixaban normal dosing; rivaroxaban 15 mg daily; edoxaban 30 mg daily; dabigatran 75 mg twice daily [US only]).

  4. CrCl less than 15 ml/min or dialysis: VKA or apixaban 2.5 mg twice daily (this would be off-label use in Europe).

  5. In patients with significant bleeding risk (HASBLED ≥ 3) then use OAC with caution; in the future, new approaches such as LAA occlusion might be available in very high-risk patients.

  6. RCT assessing safety and efficacy of apixaban versus VKA in dialysis patients are underway; results will be very important for future therapeutic guidance.