Atrial fibrillation (AF), the most common sustained arrhythmia, increases ischemic stroke and mortality risk.1 Warfarin reduces these risks but requires monitoring and has a narrow therapeutic range.2 Direct oral anticoagulants (DOACs), including apixaban and rivaroxaban, address these limitations, but pivotal trials excluded patients with advanced chronic kidney disease (CKD). Anticoagulation decisions in advanced CKD are complex because thrombosis and bleeding risks are high, and few studies have focused on longer-term medication persistence or discontinuation in this population.