Novel anticoagulants for stroke prevention in atrial fibrillation and chronic kidney disease

Abstract

Atrial fibrillation (AF) is about three-times more prevalent in patients with chronic kidney disease and the prevalence of AF increases with the degree of renal impairment. Clinical studies have shown increased risk of stroke, bleeding and death in patients with chronic kidney disease and AF. Despite, this increased risk, anticoagulation is underutilized due to increased bleeding risk in this population. Recently direct thrombin inhibitors and factor Xa inhibitors have been shown to be more efficacious in stroke prevention with reduced bleeding than warfarin. As the usage of these novel anticoagulants increases it is important to understand the data available in regard to these high risk patients.

Keywords::

• apixaban
• atrial fibrillation
• chronic kidney disease
• dabigatran
• new anticoagulants
• rivaroxaban

Financial & competing interests disclosure

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.

No writing assistance was utilized in the production of this manuscript.

Key issues

• • Atrial fibrillation (AF) is about three times more prevalent in patients with chronic kidney disease (CKD) and the prevalence of AF increases with the degree of renal impairment.

• • Patients with CKD and AF had a 1.6-fold higher rate of stroke than those without AF.

• • Studies have also demonstrated increased mortality in CKD patients with AF in those without.

• • CKD patients are at increased risk of both gastrointestinal and intracranial bleeding due to platelet dysfunction from uremic toxins and coagulopathy from poor drug clearance.

• • Three new oral anticoagulants (dabigatran, rivaroxaban and apixaban) have been recently approved across the world for stroke prevention in AF. Despite their efficacy; their usage in CKD patients is not well defined.

• • Further research is essential to describe the efficacy and safety of these drugs in patients with moderate-severe renal disease before they can be used effectively.