Atrial fibrillation is an important cause of preventable, disabling stroke and 
is particularly frequent in patients with chronic kidney disease (CKD). Stage 3 
CKD is an independent risk factor for stroke in patients with atrial 
fibrillation. Warfarin anticoagulation is efficacious for stroke prevention in 
atrial fibrillation patients with stage 3 CKD, but recent observational studies 
have challenged its value for patients with end-stage renal disease and atrial 
fibrillation. Novel oral anticoagulants such as dabigatran, apixaban and 
rivaroxaban are at least as efficacious as warfarin with reduced risks of 
intracranial haemorrhage. However, all these agents undergo renal clearance to 
varying degrees, and hence dosing, efficacy, and safety require special 
consideration in patients with CKD. Overall, the novel oral anticoagulants have 
performed well in randomized trials of patients with stage 3 CKD, with similar 
efficacy and safety profiles as for patients without CKD, albeit requiring 
dosing modifications. The required period of discontinuation of novel oral 
anticoagulants before elective surgery is longer for patients with CKD owing to 
their reduced renal clearance. Although much remains to be learned about the 
optimal use of these new agents in patients with CKD, they are attractive 
anticoagulation options that are likely to replace warfarin in coming years.