CKD G 3-5: anticoagulation with atrial fibrillation and venous thromboembolism

The decision about anticoagulation in patients with chronic kidney disease (CKD) and atrial fibrillation is difficult as such patients have a clearly elevated risk for bleeding and thrombotic events. There is an evidence-based consensus that anticoagulation with direct oral anticoagulants (DOAC) is indicated in CKD grade 3 a/b if the CHADS2-VA2SC score is = 2 (men) and = 3 (women); patients with mechanical valve replacement or with moderate to severe mitral valve stenosis require vitamin K antagonists (VKA). A similar procedure is suggested for patients with CKD grade 4. In dialysis patients the indications for anticoagulation are highly controversial as the benefits (reduction of ischemic events) are uncertain and the risk (bleeding) is substantially higher than among patients who are not dialysis dependent. When the decision for anticoagulation is made in dialysis patients, in most cases dose-adapted DOACs are superior to VKAs.