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Atrial fibrillation and chronic kidney disease commonly occur together, which poses a therapeutic dilemma due to increased risk of both systemic thromboembolism and bleeding. Chronic kidney disease also has implications for medication selection. The objective of this review is to evaluate the options for anticoagulation for thromboembolism prevention in patients with atrial fibrillation and chronic kidney disease. We searched PubMed for studies of patients with atrial fibrillation and chronic kidney disease on warfarin or a direct oral anticoagulant for thromboembolism prevention through January 1, 2018, in addition to evaluating major trials evaluating direct oral anticoagulants and warfarin use as well as society guidelines. For patients with mild to moderate chronic kidney disease, primarily observational data supports the use of warfarin, and high quality trial data and meta-analyses support the use and possible superiority of direct oral anticoagulants. For patients with severe chronic kidney disease, there are limited data on warfarin which supports its use, and data for direct oral anticoagulants is limited primarily to pharmacologic studies which support dose reductions but lack information on patient outcomes. For patients with end-stage renal disease, studies on warfarin are conflicting, but the majority suggest a lack of benefit and possible harm, and studies in direct oral anticoagulants are very limited, but apixaban may be effective and has FDA-approved labeling. In conclusion, warfarin or direct oral anticoagulants may be used based on the degree of severity of chronic kidney disease, but further study in needed in patients with end-stage renal disease. This article is protected by copyright. All rights reserved.
PMID: 30259531 [PubMed - as supplied by publisher]