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Canadian Journal of Cardiology

Anticoagulation in Patients With Advanced Chronic Kidney Disease: Walking the Fine Line Between Benefit and Harm

      Abstract

      Chronic kidney disease affects more than 3 million Canadians and is highly associated with cardiovascular diseases that require anticoagulation, such as atrial fibrillation and venous thromboembolism. Patients with chronic kidney disease are at a problematic crossroads; they are at high risk of thrombotic conditions requiring anticoagulation and bleeding complications due to anticoagulation. The limited high-quality clinical evidence to guide decision-making in this area further compounds the dilemma. In this review, we discuss the physiology and epidemiology of bleeding and thrombosis in patients with kidney disease. We specifically focus on patients with advanced kidney disease (estimated glomerular filtration rate ≤ 30 mL/min) or who are receiving dialysis and focus on the nephrologist perspective regarding these issues. We summarize the existing evidence for anticoagulation use in the prevention of stroke with atrial fibrillation and provide practical clinical recommendations for considering anticoagulation use in this population. Last, we examine specific scenarios such as the use of a glomerular filtration rate estimating equation and dosing, the use of existing prediction tools for stroke and hemorrhage risk, current patterns of anticoagulation use (including during the dialysis procedure), and vascular calcification with vitamin K antagonist use in patients with chronic kidney disease.

      Résumé

      L’insuffisance rénale chronique touche plus de trois millions de Canadiens et est fortement associée à des maladies cardiovasculaires nécessitant une anticoagulothérapie, dont la fibrillation auriculaire et la thromboembolie veineuse. Or, les patients atteints d’insuffisance rénale chronique se trouvent dans une situation doublement problématique : ils présentent à la fois un risque élevé d’affections thrombotiques nécessitant une anticoagulothérapie mais aussi de complications hémorragiques résultant de cette anticoagulothérapie. Le peu de données cliniques probantes de haute qualité susceptibles d’orienter la prise de décisions dans ce contexte complique le dilemme. Dans le présent article, nous abordons la physiologie et l’épidémiologie de l’hémorragie et de la thrombose chez les patients atteints de néphropathie. Nous mettons tout particulièrement l’accent sur le cas des patients atteints d’insuffisance rénale avancée (débit de filtration glomérulaire estimé ≤ 30 ml/min/1,73 m2) ou sous dialyse et envisageons la question du point de vue du néphrologue. Nous résumons les données probantes actuelles plaidant en faveur de l’anticoagulothérapie dans la prévention des accidents vasculaires cérébraux (AVC) en cas de fibrillation auriculaire et formulons des recommandations de pratique clinique touchant le recours aux anticoagulants au sein de cette population. Enfin, nous examinons des scénarios précis, comme l’utilisation d’une équation permettant d’estimer le débit de filtration glomérulaire et la détermination de la dose à administrer, l’utilisation des outils existants servant à prévoir le risque d’AVC et d’hémorragie, les modalités actuelles de l’anticoagulothérapie (notamment en cours de dialyse) et la calcification vasculaire associée à l’administration d’antivitamine K chez les patients atteints d’insuffisance rénale chronique.
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