What is the clinical evidence from this study?

Study design: Review. Population: Atrial fibrillation and chronic kidney disease. Intervention: Direct oral anticoagulants (DOACs) vs. Vitamin K antagonists (VKAs).

What question did this study set out to answer?

This review aims to evaluate anticoagulation strategies for patients with atrial fibrillation and chronic kidney disease, focusing on those in peritoneal dialysis.

March 26, 2026Open Access

Anticoagulation in Atrial Fibrillation and Chronic Kidney Disease: A Critical Review and Future Perspectives in Peritoneal Dialysis

AFAldo FranculliFoundation for Innovative New Diagnostics DLDi Lullo LAzienda Unità Sanitaria Locale Della Romagna PSPasquale SaporitoAzienda Unità Sanitaria Locale Della Romagna

Key Result

Direct oral anticoagulants offer significant advantages over vitamin K antagonists in nephroprotection and safety for patients with atrial fibrillation and advanced chronic kidney disease.

Key Points

This review aims to evaluate anticoagulation strategies for patients with atrial fibrillation and chronic kidney disease, focusing on those in peritoneal dialysis.
Review of current literature on atrial fibrillation and chronic kidney disease intersections.
Analysis of anticoagulant options including direct oral anticoagulants and vitamin K antagonists.
Discussion on clinical outcomes such as stroke and bleeding risks in renal replacement therapy patients.
Patients with end-stage renal disease and atrial fibrillation face increased mortality and stroke risks.
Direct oral anticoagulants may offer a better profile than vitamin K antagonists for these patients.
Evidence regarding the use of anticoagulants specifically in peritoneal dialysis remains limited.

Structured PICO

Do direct oral anticoagulants improve safety, efficacy, and renal outcomes compared to vitamin K antagonists in patients with atrial fibrillation and advanced chronic kidney disease, particularly those on peritoneal dialysis?

Population

Patients with atrial fibrillation and advanced chronic kidney disease, including end-stage renal disease on renal replacement therapy, with a specific focus on those undergoing peritoneal dialysis.

Intervention

Direct oral anticoagulants (DOACs), particularly apixaban and rivaroxaban.

Comparator

Vitamin K antagonists (VKAs) such as warfarin.

DOACs offer potential nephroprotective and safety advantages over warfarin in patients with AF and advanced CKD, highlighting an urgent need for dedicated randomized trials in the peritoneal dialysis population.

Limitations

Near-total lack of specific data in the peritoneal dialysis population
Current knowledge is mainly the result of observational studies and expert opinion

Abstract

Atrial fibrillation (AF) and chronic kidney disease (CKD) are two closely related pathophysiologically interconnected conditions, sharing common risk factors and resulting in poor clinical outcomes when coexisting. In patients with end-stage renal disease (ESRD) on renal replacement therapy, AF significantly complicates clinical management, as these patients have a doubled risk of death, stroke, and bleeding. Choosing the optimal anticoagulant strategy remains a major challenge, with direct oral anticoagulants (DOACs) emerging as a potentially superior alternative to vitamin K antagonists (VKAs), especially due to their renoprotective profile. However, data in patients on peritoneal dialysis (PD) remain sparse, constituting a significant gap in the scientific literature. This review examines the current state of evidence on anticoagulation in patients with AF and advanced CKD, with a particular focus on new therapeutic perspectives in the PD population.

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