Anticoagulation Strategies for Atrial Fibrillation in CKD Stage G5 and Dialysis Patients: An Updated Scoping Review

Abstract

Clinical trials of direct oral anticoagulants (DOACs) often exclude patients with advanced chronic kidney disease (CKD), creating uncertainty regarding their safety and efficacy compared with warfarin. This study addresses this gap by providing key insights into anticoagulation in this high-risk population. This study evaluated the effectiveness and safety of DOACs compared to warfarin and no anticoagulation therapy in atrial fibrillation (AF) patients with CKD stage G5 or on dialysis. This scoping review followed a six-stage framework and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An exhaustive search of four databases identified relevant papers published through August 2024. The data extraction process was conducted independently, with subsequent qualitative and quantitative analyses conducted. Among the 33 studies included in the final analysis, DOACs, particularly apixaban, were associated with a 20-30% decreased major bleeding risk compared to warfarin. Stroke incidence was comparable between DOACs and vitamin K antagonists (VKAs), with apixaban showing improved prevention in severe CKD. Observational studies reported slightly lower mortality rates with DOACs, particularly apixaban, including fewer cardiovascular-related deaths than with VKAs. DOACs, particularly apixaban and rivaroxaban, demonstrate a favorable safety profile compared to warfarin, but show inconsistent evidence in balancing thromboembolic prevention and bleeding risks in patients with AF and CKD stage G5 or on dialysis. Future studies should focus on optimizing dosing strategies and evaluating long-term safety and efficacy.

Keywords: anticoagulation; atrial fibrillation; chronic kidney disease; dialysis; direct oral anticoagulants.

Fig. 1.

Pathophysiological mechanisms linking chronic kidney disease and atrial fibrillation. This figure illustrates the key mechanisms that contribute to the bidirectional relationship between chronic kidney disease (CKD) and atrial fibrillation (AF). CKD promotes structural and electrical remodeling of the atria through processes such as left ventricular hypertrophy, increased sympathetic nervous system activation, systemic inflammation, oxidative stress, and endothelial dysfunction. These factors enhance atrial remodeling and arrhythmogenesis, increasing the likelihood of AF. Conversely, AF exacerbates renal dysfunction by impairing renal perfusion and promoting systemic vascular inflammation. Together, these interrelated mechanisms create a vicious cycle that amplifies cardiovascular risk in this patient population.

Fig. 2.

Study selection flowchart for inclusion in the systematic review. This flowchart outlines the study selection process for the systematic review, detailing the progression from the initial database search to the final inclusion of studies. DOAC, direct oral anticoagulant.