Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Management of thromboembolic risk in patients with atrial fibrillation and chronic kidney disease

Warren J Manning, MD
Section Editors
Bradley P Knight, MD, FACC
Jeffrey S Berns, MD
Deputy Editors
Alice M Sheridan, MD
Gordon M Saperia, MD, FACC


The presence of either atrial fibrillation (AF) or chronic kidney disease (CKD), defined as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, increases the risk of systemic thromboembolism and clinical embolic (ischemic) stroke. (See 'Stroke' below and "Atrial fibrillation: Risk of embolization", section on 'Epidemiology'.)

Antithrombotic therapy, which is recommended to decrease this risk for AF patients with one or more clinical risk factors for these adverse outcomes, and CKD are both associated with an increased risk of bleeding. (See 'Major bleeding' below and "Management of warfarin-associated bleeding or supratherapeutic INR", section on 'Bleeding risk'.)

Thus, the decision to recommend antithrombotic therapy for patients with AF and CKD requires consideration of the benefits and risks. This is not an uncommon issue, given the frequency of AF and CKD worldwide. Few studies have compared outcomes with different antithrombotic strategies in the subset of AF patients with CKD and, in particular, those with end-stage renal disease (ESRD), most of whom are receiving dialysis.

This topic will present an approach to antithrombotic therapy across the spectrum of CKD severity. The approach to antithrombotic therapy in the broad population of patients with AF is found elsewhere. (See "Atrial fibrillation: Anticoagulant therapy to prevent embolization".)


Estimates of the prevalence of CKD and AF, either alone or together, are as follows (table 1):


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: May 27, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Barsoum RS. Chronic kidney disease in the developing world. N Engl J Med 2006; 354:997.
  2. Frei U, Schober-Halstenberg HJ. Nierenersatztherapie in Deutschland. QuaSi-Niere Jahresbericht 2005/2006.
  3. Winkelmayer WC, Patrick AR, Liu J, et al. The increasing prevalence of atrial fibrillation among hemodialysis patients. J Am Soc Nephrol 2011; 22:349.
  4. European Heart Rhythm Association, Heart Rhythm Society, Fuster V, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation). J Am Coll Cardiol 2006; 48:854.
  5. Go AS, Fang MC, Udaltsova N, et al. Impact of proteinuria and glomerular filtration rate on risk of thromboembolism in atrial fibrillation: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study. Circulation 2009; 119:1363.
  6. US Renal Data System: USRDS 2005 Annual Data Report: Atlas of End-Stage Renal Disease in the United States. Bethesda, National Institutes of Health, National Institute of Diabetes, and Digestive and Kidney Diseases, 2005.
  7. Yang F, Chou D, Schweitzer P, Hanon S. Warfarin in haemodialysis patients with atrial fibrillation: what benefit? Europace 2010; 12:1666.
  8. Marinigh R, Lane DA, Lip GY. Severe renal impairment and stroke prevention in atrial fibrillation: implications for thromboprophylaxis and bleeding risk. J Am Coll Cardiol 2011; 57:1339.
  9. Atar I, Konaş D, Açikel S, et al. Frequency of atrial fibrillation and factors related to its development in dialysis patients. Int J Cardiol 2006; 106:47.
  10. Abbott KC, Trespalacios FC, Taylor AJ, Agodoa LY. Atrial fibrillation in chronic dialysis patients in the United States: risk factors for hospitalization and mortality. BMC Nephrol 2003; 4:1.
  11. K/DOQI Workgroup. K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients. Am J Kidney Dis 2005; 45:S1.
  12. Vázquez E, Sánchez-Perales C, Borrego F, et al. Influence of atrial fibrillation on the morbido-mortality of patients on hemodialysis. Am Heart J 2000; 140:886.
  13. Bozbas H, Atar I, Yildirir A, et al. Prevalence and predictors of arrhythmia in end stage renal disease patients on hemodialysis. Ren Fail 2007; 29:331.
  14. Genovesi S, Pogliani D, Faini A, et al. Prevalence of atrial fibrillation and associated factors in a population of long-term hemodialysis patients. Am J Kidney Dis 2005; 46:897.
  15. Bansal N, Fan D, Hsu CY, et al. Incident atrial fibrillation and risk of end-stage renal disease in adults with chronic kidney disease. Circulation 2013; 127:569.
  16. Goldstein BA, Arce CM, Hlatky MA, et al. Trends in the incidence of atrial fibrillation in older patients initiating dialysis in the United States. Circulation 2012; 126:2293.
  17. US Renal Data System: USRDS 2006 Annual Data Report: Atlas of End-Stage Renal Disease in the United States. Bethesda, MD, National Institutes of Health, National Institute of Diabetes, and Digestive and Kidney Diseases, 2006.
  18. Nakayama M, Metoki H, Terawaki H, et al. Kidney dysfunction as a risk factor for first symptomatic stroke events in a general Japanese population--the Ohasama study. Nephrol Dial Transplant 2007; 22:1910.
  19. Olesen JB, Lip GY, Kamper AL, et al. Stroke and bleeding in atrial fibrillation with chronic kidney disease. N Engl J Med 2012; 367:625.
  20. Piccini JP, Stevens SR, Chang Y, et al. Renal dysfunction as a predictor of stroke and systemic embolism in patients with nonvalvular atrial fibrillation: validation of the R(2)CHADS(2) index in the ROCKET AF (Rivaroxaban Once-daily, oral, direct factor Xa inhibition Compared with vitamin K antagonism for prevention of stroke and Embolism Trial in Atrial Fibrillation) and ATRIA (AnTicoagulation and Risk factors In Atrial fibrillation) study cohorts. Circulation 2013; 127:224.
  21. Zeng WT, Sun XT, Tang K, et al. Risk of thromboembolic events in atrial fibrillation with chronic kidney disease. Stroke 2015; 46:157.
  22. Hart RG, Pearce LA, Asinger RW, Herzog CA. Warfarin in atrial fibrillation patients with moderate chronic kidney disease. Clin J Am Soc Nephrol 2011; 6:2599.
  23. Banerjee A, Fauchier L, Vourc'h P, et al. Renal impairment and ischemic stroke risk assessment in patients with atrial fibrillation: the Loire Valley Atrial Fibrillation Project. J Am Coll Cardiol 2013; 61:2079.
  24. Friberg L, Benson L, Lip GY. Balancing stroke and bleeding risks in patients with atrial fibrillation and renal failure: the Swedish Atrial Fibrillation Cohort study. Eur Heart J 2015; 36:297.
  25. Vazquez E, Sanchez-Perales C, Garcia-Garcia F, et al. Atrial fibrillation in incident dialysis patients. Kidney Int 2009; 76:324.
  26. Genovesi S, Vincenti A, Rossi E, et al. Atrial fibrillation and morbidity and mortality in a cohort of long-term hemodialysis patients. Am J Kidney Dis 2008; 51:255.
  27. Bos MJ, Koudstaal PJ, Hofman A, Breteler MM. Decreased glomerular filtration rate is a risk factor for hemorrhagic but not for ischemic stroke: the Rotterdam Study. Stroke 2007; 38:3127.
  28. Go AS, Chertow GM, Fan D, et al. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004; 351:1296.
  29. Reinecke H, Brand E, Mesters R, et al. Dilemmas in the management of atrial fibrillation in chronic kidney disease. J Am Soc Nephrol 2009; 20:705.
  30. Vázquez E, Sánchez-Perales C, Lozano C, et al. Comparison of prognostic value of atrial fibrillation versus sinus rhythm in patients on long-term hemodialysis. Am J Cardiol 2003; 92:868.
  31. Limdi NA, Beasley TM, Baird MF, et al. Kidney function influences warfarin responsiveness and hemorrhagic complications. J Am Soc Nephrol 2009; 20:912.
  32. Elliott MJ, Zimmerman D, Holden RM. Warfarin anticoagulation in hemodialysis patients: a systematic review of bleeding rates. Am J Kidney Dis 2007; 50:433.
  33. Vázquez E, Sánchez-Perales C, García-Cortes MJ, et al. Ought dialysis patients with atrial fibrillation be treated with oral anticoagulants? Int J Cardiol 2003; 87:135.
  34. Holden RM, Harman GJ, Wang M, et al. Major bleeding in hemodialysis patients. Clin J Am Soc Nephrol 2008; 3:105.
  35. Kaw D, Malhotra D. Platelet dysfunction and end-stage renal disease. Semin Dial 2006; 19:317.
  36. Boccardo P, Remuzzi G, Galbusera M. Platelet dysfunction in renal failure. Semin Thromb Hemost 2004; 30:579.
  37. Falgá C, Capdevila JA, Soler S, et al. Clinical outcome of patients with venous thromboembolism and renal insufficiency. Findings from the RIETE registry. Thromb Haemost 2007; 98:771.
  38. Tveit DP, Hypolite IO, Hshieh P, et al. Chronic dialysis patients have high risk for pulmonary embolism. Am J Kidney Dis 2002; 39:1011.
  39. Gangji AS, Sohal AS, Treleaven D, Crowther MA. Bleeding in patients with renal insufficiency: a practical guide to clinical management. Thromb Res 2006; 118:423.
  40. Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009; 361:1139.
  41. Granger CB, Alexander JH, McMurray JJ, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2011; 365:981.
  42. Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 2011; 365:883.
  43. Hori M, Matsumoto M, Tanahashi N, et al. Rivaroxaban vs. warfarin in Japanese patients with atrial fibrillation – the J-ROCKET AF study –. Circ J 2012; 76:2104.
  44. Harel Z, Sholzberg M, Shah PS, et al. Comparisons between novel oral anticoagulants and vitamin K antagonists in patients with CKD. J Am Soc Nephrol 2014; 25:431.
  45. Adjusted-dose warfarin versus low-intensity, fixed-dose warfarin plus aspirin for high-risk patients with atrial fibrillation: Stroke Prevention in Atrial Fibrillation III randomised clinical trial. Lancet 1996; 348:633.
  46. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014; 130:e199.
  47. Chan KE, Lazarus JM, Thadhani R, Hakim RM. Warfarin use associates with increased risk for stroke in hemodialysis patients with atrial fibrillation. J Am Soc Nephrol 2009; 20:2223.
  48. Wizemann V, Tong L, Satayathum S, et al. Atrial fibrillation in hemodialysis patients: clinical features and associations with anticoagulant therapy. Kidney Int 2010; 77:1098.
  49. Winkelmayer WC, Liu J, Setoguchi S, Choudhry NK. Effectiveness and safety of warfarin initiation in older hemodialysis patients with incident atrial fibrillation. Clin J Am Soc Nephrol 2011; 6:2662.
  50. Shah M, Avgil Tsadok M, Jackevicius CA, et al. Warfarin use and the risk for stroke and bleeding in patients with atrial fibrillation undergoing dialysis. Circulation 2014; 129:1196.
  51. Carrero JJ, Evans M, Szummer K, et al. Warfarin, kidney dysfunction, and outcomes following acute myocardial infarction in patients with atrial fibrillation. JAMA 2014; 311:919.
  52. Lo DS, Rabbat CG, Clase CM. Thromboembolism and anticoagulant management in hemodialysis patients: a practical guide to clinical management. Thromb Res 2006; 118:385.
  53. Farooq V, Hegarty J, Chandrasekar T, et al. Serious adverse incidents with the usage of low molecular weight heparins in patients with chronic kidney disease. Am J Kidney Dis 2004; 43:531.
  54. Hirsh J, Raschke R. Heparin and low-molecular-weight heparin: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126:188S.
  55. DeCarolis DD, Thorson JG, Clairmont MA, et al. Enoxaparin outcomes in patients with moderate renal impairment. Arch Intern Med 2012; 172:1713.
  56. Hylek EM, Evans-Molina C, Shea C, et al. Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation. Circulation 2007; 115:2689.
  57. Wyse DG. Bleeding while starting anticoagulation for thromboembolism prophylaxis in elderly patients with atrial fibrillation: from bad to worse. Circulation 2007; 115:2684.
  58. Linkins LA, Choi PT, Douketis JD. Clinical impact of bleeding in patients taking oral anticoagulant therapy for venous thromboembolism: a meta-analysis. Ann Intern Med 2003; 139:893.
  59. Ritz E. Minor renal dysfunction: an emerging independent cardiovascular risk factor. Heart 2003; 89:963.