Antithrombotic Therapy in Patients With Chronic Kidney Disease

Chronic kidney disease (CKD) is a pandemic public health problem, with >500 million people worldwide estimated to have some form of kidney injury.1 Survey data suggest that the prevalence of CKD in the United States has increased between 1988 to 1994 and 1999 to 2004 from 10% to 13%, reaching a rate of 14% in 2010.2,3 Overlapping conditions such as acute kidney injury play an important role in the growing epidemiology of CKD, and underlying CKD is in turn an important risk factor for acute kidney injury and end-stage renal disease. Key factors contributing to the increased prevalence of CKD include the aging population and the growing burden of diabetes mellitus.4 The prevalence of stage 3 or 4 CKD has been reported to be ≈38% for adults ≥70 years old versus ≈1% in adults 20 to 39 years of age.2,5 Patients with diabetes mellitus are found to present with CKD in about one third of cases, with diabetic nephropathy as the most common cause of renal impairment.6 Notably, numerous epidemiological studies have shown that patients with all stages of CKD experience higher rates of atherothrombotic disease manifestations and processes with thromboembolic potential such as atrial fibrillation than the general population.7–10 This underscores the importance of antithrombotic treatment strategies in these patients. However, the risk-to-benefit ratio with antithrombotic therapies may be altered in CKD. In fact, patients with CKD also have an increased risk of bleeding complications.11–13 Importantly, bleeding has emerged as an independent predictor of adverse outcomes, including mortality.14–17 Moreover, patients with severe CKD are less likely to receive medications of proven benefit.18,19 Overall, these findings contribute to explain why patients with reduced renal function have poorer prognosis compared …