Chronic kidney disease (CKD) is prevalent in elderly patients with atrial 
fibrillation and is an independent risk factor for stroke. Warfarin 
anticoagulation is efficacious for stroke prevention in atrial fibrillation 
patients with moderate CKD (stage III, estimated glomerular filtration rate 
30-59 mL/min), but recent observational studies have challenged its value for 
patients with end-stage renal disease requiring dialysis. The novel oral 
anticoagulants (i.e., dabigatran, apixaban, rivaroxaban) all undergo renal 
metabolism to varying degrees, and hence dosing, efficacy, and safety require 
special consideration in CKD patients. In randomized trials to date involving 
11,169 patients with moderate CKD, the novel oral anticoagulants performed well, 
with similar efficacy and safety profiles as for non-CKD patients. For atrial 
fibrillation patients with stage III CKD, the available data are strongest for 
dabigatran 150 mg twice daily as superior to warfarin for stroke prevention and 
for apixaban as superior to warfarin regarding reduced major hemorrhage. Renal 
function should be monitored at least annually in patients receiving a novel 
oral anticoagulant, and more often in elderly patients and those with underlying 
CKD or comorbidities who are at special risk for dehydration and deterioration 
of renal function. Much remains to be learned about the optimal use of the novel 
oral anticoagulants in CKD patients; additional studies about optimal dosing of 
the novel oral anticoagulants and frequency of monitoring renal function in CKD 
patients with atrial fibrillation are needed. Anticoagulation options for 
hemodialysis patients require testing in randomized trials.