Role of the left atrial appendage closure in preventing thromboembolism in atrial fibrillation: what is the importance for chronic kidney disease patients?

Excerpt

Atrial fibrillation is extremely common in chronic kidney disease (CKD); furthermore, it is associated with a 50% increased likelihood of the occurrence of an ischemic stroke in patients on dialysis [1]. Prevention of thromboembolic events in patients with an estimated glomerular filtration rate (eGFR) < 30 ml/min (CKD stage G4, G5 and G5D) and atrial fibrillation remains an important and difficult challenge for the clinical nephrologist. The historical use of vitamin K antagonists (VKAs) is not supported by scientific evidence and its efficacy in thromboembolism prevention is debated, while there is evidence of increased bleeding [2]. Direct oral anticoagulants (DOACs) have been shown to be at least as effective as, and safer than VKAs in the general population and in patients with eGFR > 25 ml/min [3]. Unfortunately, two randomized controlled trials (RCTs) comparing head-to-head DOACs with warfarin in CKD G4, G5 and G5D patients have been prematurely terminated due to the lack of recruitment and have not reached the necessary statistical power to draw robust conclusions. Therefore, we currently have no clear evidence that the use of DOACs in these patients offers a real advantage in terms of efficacy and safety over VKAs [4]. Consequently, cardiology guidelines do not provide precise recommendations on how to deal with a patient with advanced CKD and atrial fibrillation. It should be noted that in Europe, unlike the US, the use of DOACs in patients with eGFR below 30 ml/min is off-label (Fig. 1).

…