Renal Failure in Atrial Fibrillation Patients | Patient Case Quiz

Teaching Points

  • To discuss the role of direct oral anticoagulants (DOACs) in dialysis patients.
  • To discuss the role of DOACs in chronic kidney disease (CKD) patients.
  • To review the association of renal disease and risk of stroke in patients with atrial fibrillation (AF).
  • To assess the risk of bleeding in patients with CKD and AF.

Case Presentation

A 77-year-old man is admitted to the hospital after a follow-up visit with his primary care physician for progressive renal disease that was found in routine blood tests. He last saw a physician one year ago. He was in his usual state of health until two weeks ago, when he describes starting to feel more fatigued than usual. He denies any chest pain, orthopnea, paroxysmal nocturnal dyspnea, shortness of breath, or leg swelling.

He has a past medical history that is significant for hypertension, type II diabetes, persistent AF, benign prostatic hyperplasia, and chronic renal disease with a baseline creatinine of 2.0 mg/dL (calculated creatinine clearance [CrCl] of 34 mL/min based on the Cockcroft-Gault equation). He has never been on dialysis in the past. His medications include amlodipine, lisinopril, metoprolol, atorvastatin, insulin, and dabigatran at a dose of 150 mg twice-daily.

Upon admission to the hospital, vital signs are notable for an irregularly irregular heart rate of 90 beats per minute, a blood pressure of 147/89 mm Hg, normal oxygen saturation on room air and a body mass index of 31. Laboratory values were notable for creatinine of 5.3 mg/dL (CrCl 11.2 mL/min), blood urea nitrogen (BUN) of 105 mg/dL, potassium of 7.0 mmol/L, and hemoglobin of 10.5 g/dL. His electrocardiogram showed AF with controlled heart rate and peaked T-waves.

He is given intravenous calcium gluconate, insulin, and dextrose followed by oral kayaxelate (sodium polystyrene). A work-up for inciting factors of worsening renal failure is negative, and he is thought to have progression of his chronic renal disease. A decision to begin hemodialysis is made and a tunneled central venous access is placed after holding dabigatran for 24 hours. No bleeding is noticed post-procedure.

After tolerating two hemodialysis sessions without complications, he is being prepared for discharge. The patient would like to resume anticoagulation for stroke prophylaxis from his AF.

Which of the following is the optimal anticoagulation strategy for this patient?

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