Atrial fibrillation is an important cause of preventable, disabling
stroke and is particularly frequent in patients with
chronic kidney disease (CKD). Stage 3 CKD is an independent risk factor for
stroke in patients with
atrial fibrillation.
Warfarin anticoagulation is efficacious for
stroke prevention in
atrial fibrillation patients with stage 3 CKD, but recent observational studies have challenged its value for patients with
end-stage renal disease and
atrial fibrillation. Novel oral
anticoagulants such as
dabigatran,
apixaban and
rivaroxaban are at least as efficacious as
warfarin with reduced risks of intracranial haemorrhage. However, all these agents undergo renal clearance to varying degrees, and hence dosing, efficacy, and safety require special consideration in patients with CKD. Overall, the novel oral
anticoagulants have performed well in randomized trials of patients with stage 3 CKD, with similar efficacy and safety profiles as for patients without CKD, albeit requiring dosing modifications. The required period of discontinuation of novel oral
anticoagulants before elective surgery is longer for patients with CKD owing to their reduced renal clearance. Although much remains to be learned about the optimal use of these new agents in patients with CKD, they are attractive anticoagulation options that are likely to replace
warfarin in coming years.