The impact of anticoagulation therapy on kidney function in patients with atrial fibrillation and chronic kidney disease

ABSTRACT

Introduction

Atrial fibrillation (AF) and chronic kidney disease (CKD) are closely related. These diseases share common risk factors and are associated with increased risk of thromboembolic events. Choosing the appropriate oral anticoagulant therapy (OAC) in patients with AF and CKD is challenging. Deterioration of renal function is common in patients with AF treated with OACs, although not all OACs affect the kidneys equally.

Areas covered

In this review, we aim to summarize the current knowledge of the prevention of thromboembolic events in patients with AF and CKD, focusing on the impact of specific OAC agents on renal function.

Expert opinion

Consideration of OAC use is mandatory in patients with AF and CKD who are at increased risk of stroke or systemic embolism. Available evidence suggests that the use of non-vitamin K antagonist oral anticoagulants (NOACs) is associated with slower deterioration of renal function in comparison to Vitamin K antagonists (VKAs). Hence, a NOAC should be used in preference to VKAs in all NOAC-eligible patients with AF and CKD. Regarding patients with end-stage renal dysfunction and those on dialysis or renal replacement therapy, the use of NOAC should be considered in line with locally relevant formal recommendations.

KEYWORDS:

• Atrial fibrillation
• chronic kidney disease
• non-vitamin K oral anticoagulants
• oral anticoagulant therapy
• vitamin K antagonists

Article highlights

• Consideration of OAC use is mandatory in patients with AF and CKD who are at increased risk of stroke or systemic embolism.

• Compared to VKAs, NOACs have a more predictable dose–response effect, lower risk of bleeding and less acute kidney injury events that lead to progressive deterioration of renal function.

• The use of NOACs is associated with slower deterioration of renal function in comparison to VKAs.

• Patients with severe renal impairment are excluded from landmark NOAC trials on stroke prevention in patients with AF.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was not funded.