Sailing Between Scylla and Charybdis: Oral Long-term Anticoagulation in Dialysis Patients

Thilo Krüger; Vincent Brandenburg; Georg Schlieper; Nikolaus Marx; Jürgen Floege

Disclosures

Nephrol Dial Transplant. 2013;28(3):534-541. 

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What About Alternatives to Vitamin K Antagonists?

Newer oral anticoagulants i.e. direct thrombin inhibitors or thrombin inhibitors, are promising alternatives for coumarins in the general population. However, these drugs are contraindicated or at least not approved for use in CKD stage 5. In CKD stages 3 and lower, the ROCKET-AF trial compared 15 mg of rivaroxaban daily (1474 patients) with target-adjusted warfarin (1476 patients) to prevent strokes. In patients with moderate renal impairment (creatinine clearance 30–49 mL/min), the group receiving warfarin developed more cerebral events and systemic embolisms than the group receiving rivaroxaban. The same protocol was applied to patients with a creatinine clearance >50 mL/min (here 20 mg/d rivaroxaban) with the same result. Nevertheless, the outcomes did not significantly differ between the treatments in either part of the trial. Although more fatal bleedings were reported in the group receiving warfarin, more gastrointestinal bleeding events occurred in the group treated with rivaroxaban than in the warfarin group, irrespective of renal function (relative risk reduction ~38% in both the cohorts). The rates of intracranial bleeding were not significantly different between the treatment groups.[35]

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