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Patients with CKD represent a vulnerable population where the risks of atrial fibrillation, ischemic stroke, and bleeding are all heightened. Although large randomized, controlled trials in the general population clearly demonstrate that the benefits of warfarin and direct-acting oral anticoagulants outweigh the risks of bleeding, no such studies have been conducted in patients when their creatinine clearance falls below 25-30 ml/min. Without randomized, controlled trial data, the role of anticoagulation in patients with CKD with atrial fibrillation remains unclear and our practice is informed by a growing body of imperfect literature such as observational and pharmacokinetic studies. This article aims to present a contemporary literature review of the benefits versus harms of anticoagulation in atrial fibrillation for patients with CKD stages 3, 4, 5, and 5 on dialysis. Although unanswered questions and areas of clinical equipoise remain, this piece serves to assist physicians in interpreting the complex body of literature and applying it to their clinical care., (Copyright © 2019 by the American Society of Nephrology.)

The article focuses on a study examining the outcomes associated with the use of apixaban, an oral factor Xa inhibitor, in atrial fibrillation patients, published in this issue. It refers to 9.2% of patients who were prescribed apixaban while warfarin was used to treat the remaining. It highlights a remarkable increase in the number of new apixaban prescriptions.