Oral anticoagulant therapy in patients with atrial fibrillation and end-stage chronic kidney disease

Patients with end-stage kidney failure have an increased risk of atrial fibrillation (AF). Chronic kidney disease (CKD) and AF share several common risk factors for the onset of the disease, as well as an increased risk of stroke, systemic thromboembolism, major bleeding and mortality. Adverse events are most common in patients with end-stage kidney disease. The risks of thromboembolism and bleeding increase with increasing severity of CKD in patients with AF. Evaluation of the advantages of oral anticoagulants (OAC) for thromboprophylaxis in patients with advanced kidney dysfunction, is a big challenge due to its deficiency of high-quality evidence from randomized clinical trials and conflicting data from observational studies. In this review, we considered the use and effects of specific OAC agents in patients with AF and end-stage kidney disease. In addition, we provide an expert opinion on the choice of optimal OAC therapy for the prevention of stroke in these patients. Patients with AF and end-stage kidney disease should benefit from the use of OAC. The use of OACs should be considered in patients with AF and end-stage kidney disease and those on dialysis or kidney replacement therapy who are at increased risk of stroke or systemic embolism in all patients eligible for OACs with AF and end-stage kidney disease (ie. those without a prosthetic mechanical heart valve or moderate to severe mitral valve stenosis). However, the effect of non-vitamin K oral anticoagulants (NOACs) on kidney function has not been sufficiently investigated. More data are needed to better understand the mechanisms of NOAC effects on kidney function, which requires clear clinical guidelines derived from randomized clinical trials.