Author + information
- Received July 10, 2019
- Revision received August 22, 2019
- Accepted August 27, 2019
- Published online October 21, 2019.
- Shankar Kumar, BSc (hons), MBBSa,b,
- Emma Lim, BSc (hons), MBChBb,
- Adrian Covic, MD, PhDc,
- Peter Verhamme, MD, PhDd,
- Chris P. Gale, MBBS, PhD, MEd, MSce,
- A. John Camm, MD, FMedScif and
- David Goldsmith, MA, MB Chirc,f,g,∗ (, )@StGeorgesUni@GSTTnhs@ucl
- aCentre for Medical Imaging, University College London, London, United Kingdom
- bImaging Department, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- cDepartment of Nephrology, University of Medicine and Pharmacy “Gr. T. Popa,” Iasi, Romania
- dDepartment of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
- eLeeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
- fMolecular and Clinical Sciences Research Institute, St. George’s University of London, London, United Kingdom
- gRenal and Transplantation Department, Guys and St. Thomas’ Hospitals NHS Foundation Trust, Great Maze Pond, London, United Kingdom
- ↵∗Address for correspondence:
Dr. David Goldsmith, Renal and Transplantation Department, Guys and St. Thomas’ Hospitals NHS Foundation Trust, Great Maze Pond, London SE1 9RT United Kingdom.
• The decision to initiate OAT poses a clinical conundrum in patients with coexisting AF and advanced CKD.
• In CKD, several pathophysiological factors result in a progressively increased risk of both ischemic stroke and hemorrhage as renal function declines, irrespective of OAT.
• The limited available data suggests that DOACs should generally be favored over VKAs in view of their probable increased safety and efficacy in CKD, with a lower risk of vascular calcification and anticoagulant-associated nephropathy.
• Until dedicated RCTs are completed to define optimal management, clinical decision-making should be informed by the limited data available, which necessitates individualization and physician-patient collaboration.
Atrial fibrillation (AF) and chronic kidney disease (CKD) often coexist as they share multiple risk factors, including hypertension, diabetes mellitus, and coronary artery disease. Although there is irrefutable evidence supporting anticoagulation in AF in the general population, these data may not be transferable to the setting of advanced CKD, where the decision to commence anticoagulation poses a conundrum. In this cohort, there is a progressively increased risk of both ischemic stroke and hemorrhage as renal function declines, complicating the decision to initiate anticoagulation. No definitive clinical guidelines derived from randomized controlled trials exist to aid clinical decision-making, and the findings from observational studies are conflicting. In this review, the authors outline the pathophysiological mechanisms at play and summarize the limited existing data related to anticoagulation in those with concomitant CKD and AF. Finally, the authors suggest how to approach the decision of whether and how to use oral anticoagulation in these patients.
- atrial fibrillation
- chronic kidney disease
- direct oral anticoagulant
- vitamin K antagonist
Dr. Kumar is supported by the National Health for National Institute for Health Research (NIHR) Academic Clinical Fellow scheme. Dr. Verhamme has received honoraria for lectures and Advisory Boards from Bayer, Boehringer Ingelheim, Pfizer, Daiichi-Sankyo, Portola, and Bristol-Myers Squibb; and has received research support from Bayer Healthcare, Boehringer Ingelheim, and Daiichi-Sankyo. Dr. Gale has received honoraria and travel expenses for speaker services from Bayer; has received honoraria for Advisory Boards from Daiichi-Sankyo: and has received an unconditional research grant from Bristol-Myers Squibb. Dr. Camm has received institutional grants and personal advisory fees from Boehringer Ingelheim, Bayer, Daiichi-Sankyo, Pfizer/Bristol-Myers Squibb, Abbott, and Boston Scientific. Dr. Goldsmith has served as a consultant and lecturer for AstraZeneca. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received July 10, 2019.
- Revision received August 22, 2019.
- Accepted August 27, 2019.
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