Anticoagulant Treatment in Patients with Atrial Fibrillation and Chronic Kidney Disease: Practical Issues

Up to 20% of patients with chronic kidney disease have atrial fibrillation, and 40%-50% of atrial fibrillation patients suffer from chronic kidney disease. The 2 diseases share several risk factors and frequently coincide with each other. Both entities are associated with a prothrombotic state, which contributes to increased thromboembolic risk. Atrial fibrillation patients with chronic kidney disease have elevated risk of stroke, major bleeding, and mortality. Clinical risk scores, including CHA(2)DS(2)-VASc score, HAS-BLED score, or ORBIT score have a limited value in adverse clinical outcome risk stratification in patients with severe chronic kidney disease. However, the inclusion of renal function in the R((2))-CHA(2)DS(2)-VASc score does not improve significantly thromboembolic risk prediction in atrial fibrillation. There is growing evidence suggesting that biomarkers, including N-terminal pro-B-type natriuretic peptide, high-sensitivity cardiac troponin, cystatin C, or growth differentiation factor-15, might be helpful in the assessment of thromboembolic, bleeding, and/or mortality risk in atrial fibrillation patients with chronic kidney disease. The first-choice anticoagulant therapy is based on direct oral anticoagulants in this subgroup. The highest risk of adverse events is observed in end-stage renal disease, and in Europe, in contrast to the USA, solely warfarin is recommended in such atrial fibrillation patients. Treatment of atrial fibrillation patients with chronic kidney disease should be closely monitored with the selection of right anticoagulant agents at the appropriate dose. The current review paper summarizes available evidence and the challenges of the management of atrial fibrillation patients with chronic kidney disease with practical implications.