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Atrial fibrillation and CKD

Chronic kidney disease (CKD), however we measure it, “signifies poor outcomes in atrial fibrillation patients”. This was a key message from Dr Ami Banerjee (University College London). Drawing on recent European Society of Cardiology guidelines,1 he outlined how atrial fibrillation (AF) is present in 15–20% of CKD patients (10–20 times higher than the general population). These patients have an increased stroke rate, and there is also a higher risk of bleeding in CKD. The big question in terms of non-valvular AF and kidney disease is: how are they related?

Guidelines suggest that renal function should be assessed in anyone with new AF, particularly in those with bleeding episodes, when considering oral anticoagulation (OAC). Impairment in renal function is included as part of several bleeding risk scores (e.g.HAS-BLED) and anticoagulation may be ruled out in those with high scores. Whilst monitoring AF patients on OACs, renal function should be checked regularly, and whilst safe in moderate and moderate-to-severe CKD (eGFR >15), dose adjustment should be considered for those on non-vitamin K novel oral anticoagulation (NOACs).

Dr Ami Banerjee (University College London)

Dr Ami Banerjee (University College London)

Around 20% of patients in trials with the four NOACS had renal dysfunction, but no studies included patients with end-stage renal disease. It also appears that in clinical practice there is reluctance throughout Europe to give renally impaired patients the full drug dose, and that a lower dose is given even in patients with mild kidney impairment. Despite that, data from The Health Improvement Network (THIN) database, a national GP prescribers’ database, showed that in the UK there is greater prescribing of NOACs in moderate and moderate to severe renal failure than warfarin.

A recently published meta-analysis of four randomised controlled trials (RCTs) compared efficacy and safety (major bleeding) of NOACs versus warfarin in over 58,000 patients, including data on renal function.2 It showed that use of NOACs was associated with a reduced risk of stroke, systemic embolism and major bleeding compared to warfarin in individuals with mild or moderate renal impairment, suggesting a favourable risk profile for these agents in patients with renal disease. However, there is very little data regarding the use of NOACs in end-stage renal disease, and the severe end of the spectrum appears to be neglected. At this time, there are no RCTs assessing OACs in haemodialysis patients or following kidney transplantation, nor studies of NOACs in those with severe CKD (i.e. a creatinine clearance <25-30ml/min). This severe end of the CKD spectrum needs to be addressed in the future.


1. Kirchhof P, Benussi S, Kotecha D, et al. (The Task force for the Management of Atrial Fibrillation of the European Society of Cardiology). ESC 2016 European Society of Cardiology Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016;117:1-90.

2. Munoz F, Gharacholou SM, Munger TM, et al. Meta-analysis of renal function on the safety and efficacy of novel oral anticoagulants for atrial fibrillation. Am J Cardiol 2016;17:69-75.

Published on: February 21, 2017

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  • ArrhythmiaAlliance
  • Stars
  • Anticoagulation Europe
  • Atrial Fibrillation Association

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