Nonvitamin K Anticoagulant Agents in Patients With Advanced Chronic Kidney Disease or on Dialysis With AF

J Am Coll Cardiol. 2016 Jun 21;67(24):2888-99. doi: 10.1016/j.jacc.2016.02.082.

Abstract

Nonvitamin K-dependent oral anticoagulant agents (NOACs) are currently recommended for patients with atrial fibrillation at risk for stroke. As a group, NOACs significantly reduce stroke, intracranial hemorrhage, and mortality, with lower to similar major bleeding rates compared with warfarin. All NOACs are dependent on the kidney for elimination, such that patients with creatinine clearance <25 ml/min were excluded from all the pivotal phase 3 NOAC trials. It therefore remains unclear how or if NOACs should be prescribed to patients with advanced chronic kidney disease and those on dialysis. The authors review the current pharmacokinetic, observational, and prospective data on NOACs in patients with advanced chronic kidney disease (creatinine clearance <30 ml/min) and those on dialysis. The authors frame the evidence in terms of risk versus benefit to bring greater clarity to NOAC-related major bleeding and efficacy at preventing stroke specifically in patients with creatinine clearance <30 ml/min.

Keywords: apixaban; dabigatran; edoxaban; renal dialysis; rivaroxaban; stroke.

Publication types

  • Review

MeSH terms

  • Anticoagulants / pharmacokinetics*
  • Anticoagulants / therapeutic use
  • Atrial Fibrillation / drug therapy*
  • Creatinine / urine
  • Dabigatran / pharmacokinetics
  • Dabigatran / therapeutic use
  • Glomerular Filtration Rate
  • Hemorrhage / chemically induced
  • Humans
  • Kidney / metabolism*
  • Kidney Failure, Chronic / complications
  • Kidney Failure, Chronic / therapy
  • Pyrazoles / pharmacokinetics
  • Pyrazoles / therapeutic use
  • Pyridines / pharmacokinetics
  • Pyridines / therapeutic use
  • Pyridones / pharmacokinetics
  • Pyridones / therapeutic use
  • Renal Dialysis*
  • Renal Insufficiency, Chronic / complications*
  • Renal Insufficiency, Chronic / therapy*
  • Rivaroxaban / pharmacokinetics
  • Rivaroxaban / therapeutic use
  • Stroke / prevention & control*
  • Thiazoles / pharmacokinetics
  • Thiazoles / therapeutic use
  • Warfarin / pharmacokinetics
  • Warfarin / therapeutic use

Substances

  • Anticoagulants
  • Pyrazoles
  • Pyridines
  • Pyridones
  • Thiazoles
  • apixaban
  • Warfarin
  • Rivaroxaban
  • Creatinine
  • Dabigatran
  • edoxaban