. 2023 Jun 19;5(9):100690. doi: 10.1016/j.xkme.2023.100690

Table 2.

Summary Practice Points Across the Spectrum of Chronic Kidney Disease

	Practice Points
General population⁸	• A risk factor approach to stroke risk assessment recommended, using the CHA₂DS₂VASc score to initially identify people at “low stroke risk” (score = 0 in men or 1 in women) who should not be offered OAC • OAC is recommended for stroke prevention in people with AF with CHA₂DS₂VASc ≥2 in men or ≥3 in women • In people who are eligible for OAC, DOACs are recommended in preference to VKAs (excluding people with mechanical heart valves or mitral stenosis) • A structured risk-score-based bleeding risk assessment (such as the HAS-BLED) is recommended to identify nonmodifiable and address modifiable bleeding risk factors • Stroke and bleeding risk reassessment is recommended at periodic intervals to inform treatment decisions and address potentially modifiable bleeding risk factors • Clinical pattern of AF (ie, first detected, paroxysmal, persistent, or permanent) should not condition the indication to OAC use
Advanced CKD (15-29 mL/min/1.73 m²)	• Commonly used stroke and bleeding risk assessment scores did not include people with advanced CKD in validation cohorts, and predictive performance is poor¹⁰ • There is little randomized data on DOAC use in advanced CKD, and treatment decisions in people with declining kidney function is challenging • Apixaban may be used down to a CrCl of 25 mL/min based on the inclusion criteria of the ARISTOTLE trial and subgroup analysis⁵⁰ • Observational cohort data suggests rivaroxaban may efficacious and safe when used in CrCl <30 mL/min compared with VKA use⁵¹
Kidney failure (eGFR <15 mL/min/1.73 m²)	• Stroke and bleeding risk are both disproportionately high in kidney failure • The Dialysis Risk Score¹³ may be used to identify people with kidney failure who may derive net clinical benefit from OAC • VKAs should only be used in select people who may derive substantial benefit without significant bleeding risk. Meta-analyses of observational data report increased major bleeding risk without significant reduction in ischemic stroke or mortality risk.² • Apixaban and rivaroxaban may be used in kidney failure based on limited data suggesting equivocal or reduced bleeding risk compared with VKAs.³^,⁴ Due to underpowered trial data, efficacy data for stroke risk reduction remains outstanding.

Abbreviations: AF, atrial fibrillation; CKD, chronic kidney disease; CrCl, creatinine clearance; DOAC, direct oral anticoagulant; eGFR, estimated glomerular filtration rate; OAC, oral anticoagulation; VKA, vitamin K antagonist.