Comparative efficacy and safety of apixaban and rivaroxaban versus warfarin in atrial fibrillation patients with end-stage renal disease: a systematic review and meta-analysis

Clinical Snapshot

Key Findings

• P Value: Not explicitly reported

• Effect Size: 43% reduction in stroke/systemic embolism, 27% reduction in mortality with DOACs

• Primary Outcome: Stroke/systemic embolism: RR 0.57 (95% CI: 0.46-0.72) favoring DOACs; All-cause mortality: RR 0.73 (95% CI: 0.63-0.83) favoring DOACs

• Nnt Or Sensitivity: Major bleeding reduction: RR 0.57 (95% CI: 0.51-0.63); Intracranial hemorrhage: RR 0.54 (95% CI: 0.36-0.83)

• Confidence Interval: 95% CI provided for all outcomes

Clinical Application

DOACs are available but dosing in ESRD remains challenging without clear guidelines TGA-approved DOACs available on PBS for AF, but ESRD represents off-label use requiring specialist consultation and careful monitoring AF patients with ESRD on dialysis, though evidence quality limits definitive recommendations

Abstract

This study aimed to evaluate the comparative efficacy and safety of apixaban and rivaroxaban versus vitamin K antagonists (VKAs) in anticoagulation management in a dialysis population. PubMed, Embase, and the Cochrane Library were searched for studies comparing apixaban or rivaroxaban with VKAs in patients with atrial fibrillation (AF) undergoing dialysis. The primary efficacy endpoints included stroke/systemic embolism (SSE) and all-cause mortality. Safety outcomes encompassed major bleeding, intracranial hemorrhage, and gastrointestinal bleeding. Risk ratios (RR) with 95% confidence intervals (CI) were synthesized using random-effects models. The meta-analysis included three randomized controlled trials (RCTs) and eight observational studies. Pooled analyses showed that apixaban and rivaroxaban were associated with lower risks of major bleeding (RR 0.57, 95% CI: 0.51-0.63), gastrointestinal bleeding (RR 0.66, 95% CI: 0.57-0.76), and intracranial hemorrhage (RR 0.54, 95% CI: 0.36-0.83) compared with VKAs. Additionally, apixaban and rivaroxaban were associated with reduced risk of SSE (RR 0.57, 95% CI: 0.46-0.72) and all-cause mortality (RR 0.73, 95% CI:0.63-0.83), although substantial heterogeneity was present. Exploratory dose-stratified analyses suggested both standard- and low-dose apixaban regimens were associated with favorable efficacy and hemostatic safety relative to warfarin. Consistent numerical trends were observed in the RCT-only analysis, though none reached statistical significance owing to limited sample size. In conclusion, apixaban and rivaroxaban are associated with lower risks of bleeding compared with VKAs in patients with AF and ESRD. However, evidence regarding their efficacy in preventing SSE, all-cause mortality and the optimal apixaban dosing regimen remains inconclusive and requires validation in large, dedicated RCTs.

References

1. 1.Wu, X., Meng, J., Yang, Y., Sheng, D., Liu, X., & Zhou, Y. (2026). Comparative efficacy and safety of apixaban and rivaroxaban versus warfarin in atrial fibrillation patients with end-stage renal disease: a systematic review and meta-analysis. Renal Failure. https://doi.org/10.1080/0886022X.2026.2666454