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Direct oral anticoagulants in patients with chronic kidney disease: patient selection and special considerations

Authors Lutz J, Jurk K, Schinzel H

Received 12 December 2016

Accepted for publication 22 March 2017

Published 12 June 2017 Volume 2017:10 Pages 135—143


Checked for plagiarism Yes

Review by Single-blind

Peer reviewers approved by Dr Akshita Wason

Peer reviewer comments 3

Editor who approved publication: Professor Pravin Singhal

Jens Lutz,1 Kerstin Jurk,2 Helmut Schinzel3

1Nephrology Department, I. Medizinische Klinik und Poliklinik, 2Center for Thrombosis and Hemostasis, Universitätsmedizin Mainz, 3Cardiopraxis Mainz, Gerinnungsambulanz, MED Facharztzentrum, Mainz, Germany

Many patients with chronic kidney disease (CKD) receive anticoagulation or antiplatelet therapy due to atrial fibrillation, coronary artery disease, thromboembolic disease, or peripheral artery disease. The treatment usually includes vitamin K antagonists (VKAs) and/or platelet aggregation inhibitors. The direct oral anticoagulants (DOAC) inhibiting factor Xa or thrombin represent an alternative for VKAs. In patients with acute and chronic kidney disease, caution is warranted, as DOACs can accumulate as they are partly eliminated by the kidneys. Thus, they can potentially increase the bleeding risk in patients with CKD. In patients with an estimated glomerular filtration rate (eGFR) above 60 mL/min, DOACs can be used safely with greater efficacy and safety as compared to VKAs. In patients with CKD 3, DOACs are as effective as VKAs with a lower bleeding rate. The more the renal function declines, the lower is the advantage of DOACs over VKAs. Thus, use of DOACs should be avoided in patients with an eGFR below 30 mL/min, particularly, the compounds with a high renal elimination. Available data suggest that DOACs can also be used safely in older patients. In this review, use of DOACs in comparison with VKAs, heparins, and heparinoids, together with special considerations in patients with impaired renal function will be discussed.

chronic renal disease, anticoagulation, renal function, vitamin K antagonists, bleeding, atrial fibrillation, dosing

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