Review ArticleNonvitamin K-dependent oral anticoagulants (NOACs) in chronic kidney disease patients with atrial fibrillation

- Atrial fibrillation is the most common arrhythmia in patients with chronic kidney disease (CKD)
- The use of NOACs in CKD is limited by the drug accumulation but it 's becoming more common even in subjects with advanced CKD
- Preliminary data support efficacy and safety of NOACs in CKD, although further efforts are needed to evaluate safety profile in ESRD patients
- The development of specific antidotes for NAOC as well as results of ongoing trials may allow larger use of these drugs in patients with advanced CKD

Atrial fibrillation (AF) represents the most common arrhythmia in patients with chronic kidney disease (CKD). As in the general population, in CKD patients AF is associated with an increased risk of thromboembolism and stroke. However, CKD patients, especially those on renal replacement therapy (RRT), also exhibit an increased risk of bleeding, especially from the gastrointestinal tract.Oral anticoagulation is the most effective form of thromboprophylaxis in patients with AF presenting increased risk of stroke. Limited evidence on efficacy, the increased risk of bleeding as well as some concern regarding the use of warfarin in CKD, has often resulted in the underuse of anticoagulation CKD patients.A large body of evidence suggests that non-vitamin K-dependent oral anticoagulant agents (NOACs) significantly reduce the risk of stroke, intracranial hemorrhage, and mortality, with lower to similar major bleeding rates compared with vitamin K antagonist such as warfarin in normal renal function subjects. Hence, they are currently recommended for patients with atrial fibrillation at risk for stroke. However, NOACs metabolism is largely dependent on the kidneys for elimination and little is known in patients with creatinine clearance < 25 ml/min who were excluded from all pivotal phase 3 NOACs trials.This review focuses on the current pharmacokinetic, observational, and prospective data on NOACs in patients with moderate to advanced chronic kidney disease (creatinine clearance 15-49 ml/min) and those on dialysis.