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Triple Antithrombotic Bleeding Risk CKD — ESENeph MCQ

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HardChronic Kidney DiseaseTriple Antithrombotic Bleeding Risk CKDESENeph

A 60-year-old man with CKD G4 is prescribed Apixaban for atrial fibrillation. He also needs antiplatelet therapy after a coronary stent. He is on Aspirin 75 mg and Clopidogrel 75 mg. His cardiologist wants triple therapy (DOAC + dual antiplatelet). What is the concern in CKD?

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Correct answer: A — Triple antithrombotic therapy dramatically increases bleeding risk which is already elevated in CKD – the duration should be minimised (typically 1 week to 1 month) and DOAC dose potentially reduced; early discussion between cardiology and nephrology is essential

CKD patients have a paradoxically increased risk of both thrombosis AND bleeding (uraemic platelet dysfunction, vascular fragility, medication accumulation). Triple antithrombotic therapy (DOAC + Aspirin + P2Y12 inhibitor) in CKD dramatically amplifies bleeding risk. Current ACS/PCI guidelines (ESC 2020) recommend minimising triple therapy duration (1 week for low bleeding risk, up to 1 month for high thrombotic risk) then stepping down to dual therapy (DOAC + single antiplatelet). CKD-specific considerations include DOAC dose adjustment, use of lowest effective Aspirin dose, and PPI gastroprotection.

Reference: ESC 2020 – AF/ACS; NICE NG185 – ACS; KDIGO 2024 – CKD