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  • Review Article
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Use of oral anticoagulants in patients with atrial fibrillation and renal dysfunction

Nature Reviews Nephrology volume 14, pages 337–351 (2018)Cite this article

Subjects

Key Points

  • Atrial fibrillation (AF) and chronic kidney disease (CKD) share common risk factors, including older age, hypertension and diabetes mellitus.

  • CKD increases the risk of incident AF, whereas AF increases the risk of development and progression of CKD.

  • AF and CKD are associated with an increased risk of thromboembolic events; patients with severe CKD also exhibit a paradoxical increase in bleeding risk.

  • In trials that compared non-vitamin K antagonist oral anticoagulants (NOACs) with warfarin, the relative efficacy and safety of NOACs were consistent in patients with and without mild or moderate CKD.

  • Patients with end-stage renal disease (ESRD) were excluded from NOAC trials; these patients are at high risk of thromboembolism and bleeding, but no high-quality evidence exists to guide their management.

  • In patients with ESRD, vitamin K antagonists might increase the risk of bleeding and thrombotic events; however, good anticoagulation control might reduce the risk of ischaemic stroke without increasing bleeding risk.

Abstract

Atrial fibrillation (AF) and chronic kidney disease (CKD) are increasingly prevalent in the general population and share common risk factors such as older age, hypertension and diabetes mellitus. The presence of CKD increases the risk of incident AF, and, likewise, AF increases the risk of CKD development and/or progression. Both conditions are associated with substantial thromboembolic risk, but patients with advanced CKD also exhibit a paradoxical increase in bleeding risk. In the landmark randomized clinical trials that compared non-vitamin K antagonist oral anticoagulants (NOACs) with warfarin for thromboprophylaxis in patients with AF, the efficacy and safety of NOACs in patients with mild-to-moderate CKD were similar to those in patients without CKD. Dose adjustment of NOACs as per the prescribing label is required in this population. Owing to limited trial data, evidence-based recommendations for the management of patients with AF and severe CKD or end-stage renal disease on dialysis are lacking. Observational cohort studies have reported conflicting results, and the management of these particularly vulnerable patients remains challenging and requires careful assessment of stroke and bleeding risk and, where appropriate, use of warfarin with good-quality anticoagulation control.

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Figure 1: Pathophysiology of prohaemorrhagic conditions in patients with CKD.
Figure 2: The pathophysiology of prothrombotic conditions in patients with AF and CKD.
Figure 3: Algorithm for the use of oral anticoagulant therapy in patients with AF and CKD.

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Authors and Affiliations

  1. School of Medicine, Belgrade University, Belgrade, Serbia

    Tatjana S. Potpara & Gregory Y. H. Lip

  2. Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia

    Tatjana S. Potpara

  3. Institute of Cardiovascular Science, University of Birmingham, Birmingham, United Kingdom

    Charles J. Ferro & Gregory Y. H. Lip

  4. Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark

    Gregory Y. H. Lip

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All authors researched the data for this article, wrote the text and reviewed or edited the manuscript before submission.

Corresponding author

Correspondence to Gregory Y. H. Lip.

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Competing interests

G.Y.H.L. is a consultant for Bayer/Janssen, BMS/Pfizer, Biotronik, Medtronic, Boehringer Ingelheim, Novartis, Verseon and Daiichi-Sankyo and a speaker for Bayer, BMS/Pfizer, Medtronic, Boehringer Ingelheim and Daiichi-Sankyo. He does not personally receive any fees from these companies. T.S.P. declares no competing interests.

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Glossary

Concentric LVH

Increased left ventricle muscle mass in response to high pressure load (for example, due to chronic hypertension).

Renal microinfarcts

Small areas of renal tissue damage due to ischaemia.

Virchow's triad

The concept that three abnormalities predispose to thrombus formation: abnormal blood flow, abnormal blood constituents and abnormal vessel walls.

Left ventricular afterload

The pressure against which the heart must work to eject blood during systole.

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Potpara, T., Ferro, C. & Lip, G. Use of oral anticoagulants in patients with atrial fibrillation and renal dysfunction. Nat Rev Nephrol 14, 337–351 (2018). https://doi.org/10.1038/nrneph.2018.19

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