Thromboembolic Prophylaxis in Patients with AFib and CKD: Caught between the Devil and the Deep Blue Sea

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I often get curb-sided by cardiologists and internists for
my opinion on using warfarin or other anticoagulants for thromboembolic risk
prophylaxis in CKD +/- Afib patients. A similar conundrum of using
anticoagulation for stroke prophylaxis in dialysis patients was discussed about
years ago on this blog
by Conall. Like many other issues in patients with
CKD, things are not always black-and-white, and a lot could depend on patient
and physician preference.  This often
makes the “right answer” a confusing exercise, since CKD patients are also at a
higher bleeding risk. Most randomized trials addressing this issue have
excluded patients with a GFR below 30. Furthermore, newer direct thrombin
inhibitors (dabigatran), or Factor Xa inhibitors
(apixaban, rivaroxaban) are available, which might be better than warfarin, at
least in the early-CKD patient (although the lack of a reversing antidote is a
potential pitfall). Finally, warfarin has a well-established link with vascular
calcification (a mortality risk) in dialysis patients. As nephrologists, it is
imperative that we are knowledgeable about the best-available data that can
help us make an evidence-based recommendation, and so I put together a concise
decision-table with links to primary literature sources.
In addition to the “traditional” risk factors for stroke in
patients with AFib (as exemplified by the acronym CHADS), it is known that CKD itself
is an independent risk factor for stroke. Thus CKD patients, both with, and without
AFib, are at an increased risk of stroke. This has been demonstrated in CKD as well as dialysis patients, and the risk
worsens with decline in GFR. 
Thus, with the above background in mind, the two main
variables that determine what, if any, anticoagulation is to be used in this
setting, are (1) the stage of CKD, and (2) the CHADS2 score:

CHADS2 Score
Stage 3, eGFR 30-59
Stage 4, eGFR 15-29
Stage 5, eGFR less than 15, or dialysis
AC (Direct thrombin inhibitors (dabigatran), and
Factor Xa inhibitors (rivaroxaban, apixaban)
potentially superior to warfarin
AC (warfarin preferred since no data on direct thrombin
or factor
Xa inhibitors
AC (warfarin preferred since no data on direct thrombin
or factor
Xa inhibitors


ASA = Aspirin
AC = Anticoagulation
?? = Expert opinion only, no strong evidence available – weight risks vs. benefits
Remember that no antithrombotic therapy is warranted if bleeding is a concern
Posted by Veeraish Chuahan
(Apologies for any formatting issues)

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