NUANCES IN ANTICOAGULATION TREATMENT IN PATIENTS WITH CHRONIC KIDNEY DISEASE AND ATRIAL FIBRILLATION

Glomerular filtration rate (GFR) declines with normal aging beyond 50 years. The number of persons with atrial fibrillation (AF) and chronic kidney disease (CKD) is increasing annually. The risk of ischemic stroke or systemic thromboembolism as well as the risk of bleeding events in patients with AF and coexisting renal dysfunction is significantly higher than in those with normal kidney function. Four randomized controlled trials demonstrated advantages of novel direct oral anticoagulants (DOACs) over warfarin, but these studies had significant limitations, including relatively few patients with advanced CKD. ROCKET-AF differed from other trials (RE-LY, ARISTOTLE) by higher stroke and bleeding risk profile of included patients with AF as assessed by CHADS(2) and HASBLED scores. International normalized ratio beyond therapeutic window is associated with worsening renal function in warfarin-treated patients. Dose reduction of DOACs is needed in patients with clinically significant renal dysfunction because all of them are to some extent excreted by the kidneys. Failure to follow the recommendation to reduce the dose in patients with renal impairment increases the risk of bleeding, on the other hand incorrect dose reduction without clear indication may lower effectiveness of stroke prevention. In this review article we discuss pharmacological properties of DOACs depending on the degree of renal impairment, important nuances to be considered while choosing anticoagulant therapy with a DOAC in a patient with coexisting AF and CKD.