Anticoagulant therapy in patients with atrial fibrillation and chronic kidney disease stage G4-G5 — systematic review

Atrial fibrillation (AF) is a common arrhythmia in patients with chronic kidney disease (CKD). The need for anticoagulant therapy in this patient population presents a significant clinical challenge, particularly in advanced stages of CKD, due to the increased risk of both thromboembolic and hemorrhagic complications. This systematic review presents the latest data on the safety and efficacy of anticoagulant therapy in patients with AF and CKD with a glomerular filtration rate (GFR) < 30 mL/min/1.73 m², including those undergoing dialysis. A search of databases (PubMed and MEDLINE Ultimate) and the ClinicalTrials.gov registry let identify 14 published studies and 2 ongoing trials that met the inclusion criteria. The analysis of this data suggests that initiation of anticoagulation therapy in patients with AF and CKD stages G4–G5D should be considered only in individuals for whom the benefits outweigh the risks of complications, and this decision should be made together with the patient. The choice of treatment should be based on the latest available data, which in this patient population comes mainly from observational studies. Guidelines from scientific societies such as the ESC/EHRA, AHA, and KDIGO do not provide an unequivocal stance regarding anticoagulation therapy in patients with AF and advanced CKD (GFR < 30 mL/min/1.73 m²). Most analyses point to apixaban as a safer alternative to vitamin K antagonists. While maintaining an adequate anticoagulant effect, its use is associated with a lower risk of bleeding complications and renal function deterioration. The main limitation of the analysed studies is their observational nature; however, these studies currently represent the primary source of knowledge and may serve as valuable support in making therapeutic decisions for this patient population.