When direct oral anticoagulants (DOACs) are used in patients with chronic kidney disease (CKD), they are eliminated by kidneys which may create problems with their use or may require dosage adjustments in patients with CKD. Direct oral anticoagulants-dabigatran, rivaroxaban, apixaban, edoxaban, and betrixaban are anticoagulation pharmacotherapy used to prevent thrombosis in severe cardiovascular contexts. There are two types of oral anticoagulants; oral direct factor Xa inhibitors-rivaroxaban, apixaban, edoxaban, betrixaban, and direct thrombin inhibitors-dabigatran. 

DOACs may be used in patients with advanced chronic kidney disease after proper adjustment of doses. There is some evidence available comparing the use of DOACs with no treatment or warfarin in patients with atrial fibrillation and maintenance dialysis. In a randomized controlled trial, there was no significant difference in vascular calcification between patients receiving rivaroxaban with or without vitamin K2 or vitamin K antagonists. Another trial on apixaban compared with warfarin showed no difference in clinical outcomes between the two treatment groups. Another study showed that apixaban was related to reduced bleeding compared to warfarin. Besides, when apixaban was given in 5 mg twice daily dose, it was associated with a low risk of ischemic stroke or systemic embolism; however, the same association was not seen with a reduced dose of 2.5 mg twice daily. 

Reference:

1. Mavrakanas TA, Charyton DM, Winkelmayer WC. Direct oral anticoagulants in chronic kidney diseases: an update. Current Opinion in Nephrology and Hypertension. 2020; 29: 489-496.
2. Chen A, Stecker E, Warden BA. Direct oral anticoagulant use: A practical guide to common clinical challenges. Journal of the American Heart Association. 2020; 9: e017559.