Remark: With VKA, good quality anticoagulation control (TTR > 65-70%) is recommended. 52. In severe non-dialysis CKD (Stage IV, CrCl 15- 30 mL/min), we suggest using VKAs and selected NOACs (rivaroxaban 15 mg QD, apixaban 2.5 mg bid, edoxaban 30 mg QD and [in USA only] dabigatran 75 mg bid) with caution, based on pharmacokinetic data (Ungraded consensus-based statement). 53. In end-stage renal disease (CrCl < 15 mL/min or dialysis-dependent), we suggest that individualized decision-making is appropriate (Ungraded consensus- based statement). 54. In end-stage renal disease (CrCl < 15 mL/min or dialysis-dependent, we suggest using well- managed VKA with TTR > 65-70% (Ungraded consensus-based statement). Remark: NOACs should generally not be used, although in USA, apixaban 5 mg bid is approved for use in AF patients receiving hemodialysis. CrCl If TTR 70% 150 mg bida (or 110 mg bid) 150 mg bid (or non-US, 110 mg bid)a 75 mg bid in USa 15 mg qd 2.5 mg bid 5 mg bid in US onlyb 30 mg qd 5 mg bidb 30 mg qd 5 mg bidb 15 mg qd 20 mg qd 60 mg qd Closely monitor renal function, especially in NOAC users. Schedule for frequent clinical follow-up, look for development of new cardiovascular risk factors, comorbidities. Reassess and address bleeding risk factors. (Outside US) (Outside US) If TTR 70% If TTR 70% If TTR 70% Drug VKA Dabigatran Rivaroxaban Apixaban Edoxaban CrCl CrCl CrCl <15 mL/min or ESRD on RRT Figure 9 Suggested algorithm for the decision-making process in prescribing OAC therapy in patients with various degrees of renal function impairment. a The 110-mg dose is not available in the United States. 