Contemporary anticoagulation management across the spectrum of kidney disease: a narrative review and expert Recommendations by Kasralainy Nephrology Group (KANG)

Abstract

Abstract Background Chronic kidney disease (CKD) presents a significant clinical challenge for anticoagulation therapy due to the coexistence of elevated thromboembolic risk and increased bleeding tendency. Management is further complicated by altered pharmacokinetics, limited high-quality evidence in advanced CKD, and the systematic exclusion of patients with severely reduced kidney function from major trials. Purpose This narrative review synthesizes existing evidence and provides practical, expert-panel–assessed recommendations regarding anticoagulation therapy across the full spectrum of CKD. Findings Evidence quality varies substantially across CKD stages. Warfarin has traditionally been used in advanced CKD and kidney failure on dialysis because of hepatic metabolism, although its role remains controversial given conflicting observational data on efficacy and substantial safety concerns (low certainty, expert assessment). Direct oral anticoagulants (DOACs), particularly apixaban, may be considered in CKD stages 3–4 after appropriate dose adjustment based on Cockcroft–Gault creatinine clearance (CrCl) rather than eGFR alone (moderate certainty, conditional recommendation). Specific management strategies are required for major versus non-major bleeding, with different reversal-agent approaches. Conclusion Anticoagulation in CKD requires individualized, shared decision-making that balances thrombotic and bleeding risks while acknowledging substantial uncertainty, especially in advanced CKD and dialysis populations. No single strategy, including withholding anticoagulation, can be regarded as generally preferred. This review provides practical, stage- and CrCl-specific guidance and explicitly identifies priority areas for future research.