Anticoagulation for atrial fibrillation in adults with advanced kidney disease: UK kidney association clinical practice guideline

Patients with chronic kidney disease (CKD) have an increased risk of developing atrial fibrillation (AF). CKD is also associated with an increased risk of stroke and systemic embolism (SSE). Despite the increased thromboembolic risk associated with CKD and AF, patients with advanced CKD simultaneously have a higher risk of bleeding. Following results from large randomised controlled trials prophylaxis of thromboembolic events from atrial fibrillation (AF) has shifted from vitamin K antagonists (VKAs) to direct oral anticoagulants (DOACs). However, trials of DOACs excluded patients with advanced kidney disease (CrCl < 30 ml/min), therefore good-quality data are limited in this population. This leads to decision-making around anticoagulation difficult. In those with advanced kidney disease, especially those on dialysis, there is limited data on the efficacy of anticoagulants for AF in terms of stroke reduction. There are ongoing studies to determine efficacy of anticoagulants in reducing the risk of thromboembolic stroke and systemic embolism in this population. These UK Kidney Association (UKKA) guidelines, which have been endorsed by the British Cardiovascular Society, provide best-practice guidance on the use of anticoagulants for atrial fibrillation in the context of advanced CKD. There are recommendations about the option of no anticoagulation, the use of DOACs, the monitoring of anticoagulants and the use of left atrial appendage occlusion. It also includes research recommendations.