Atrial Fibrillation and Oral Anticoagulation in Chronic Kidney Disease

Abstract

Due to several unfavorable epidemiological changes, chronic kidney disease (CKD) and treatment of its associated cardiovascular morbidity have become a worldwide problem. Thus, atrial fibrillation (AF) is the most common arrhythmia and frequently associated with renal impairment: prevalence for AF is up to 27% in long-term hemodialysis patients and in general more than 25% in all CKD patients 70 years and older. Thromboembolism and stroke are the major complications of AF. Two-year death rates for CKD patients after stroke range between 55% and 74%. Although treatment of AF in the general population is well defined, patients with CKD and AF are often undertreated due to lack of studies and guidelines. In this review recent data concerning incidence and prevalence of AF, stroke, and major bleedings in CKD patients are presented. Particular attention is paid to the available data about the different types of oral anticoagulation therapy with regard to CKD stage, including the new oral anticoagulant drugs dabigatran, rivaroxaban, and apixaban. Stratification algorithms for stroke risk in general, and individualized risk stratification for oral anticoagulation in CKD patients are discussed in detail.

Figure 1.. Prevalence of atrial fibrillation is shown in the general population, and in patients with different stages of chronic kidney disease (CKD) including end-stage renal disease (ESRD). In some studies, different stages are pooled together which is indicated by wider srectangles above the CKD stages. CKD stage 1: eGFR ≥ 90 ml/min/1.73m²; CKD stage 2: eGFR 60-89 ml/min/1.73m²; CKD stage 3: eGFR 30-59 ml/min/1.73m²; CKD stage 4: eGFR 15-29 ml/min/1.73m²; CKD stage 5: eGFR <15 ml/min/1.73m²