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. 2024 Apr 16;13(8):e034176.
doi: 10.1161/JAHA.123.034176. Epub 2024 Apr 12.

Anticoagulation for Patients With Concomitant Atrial Fibrillation and End-Stage Renal Disease: A Systematic Review and Network Meta-Analysis

Ting-Wei Kao  1 , Zheng-Wei Chen  1   2   3 , Yen-Hung Lin  1
Affiliations

Anticoagulation for Patients With Concomitant Atrial Fibrillation and End-Stage Renal Disease: A Systematic Review and Network Meta-Analysis

Ting-Wei Kao et al. J Am Heart Assoc. .

Abstract

Background: Concomitant atrial fibrillation and end-stage renal disease is common and associated with an unfavorable prognosis. Although oral anticoagulants have been well established to prevent thromboembolism, the applicability in patients under long-term dialysis remains debatable. The study aimed to determine the efficacy and safety of anticoagulation in the dialysis-dependent population.

Methods and results: An updated network meta-analysis based on MEDLINE, EMBASE, and the Cochrane Library was performed. Studies published up to December 2022 were included. Direct oral anticoagulants (DOACs, dabigatran, rivaroxaban, apixaban 2.5/5 mg twice daily), vitamin K antagonists (VKAs), and no anticoagulation were compared on safety and efficacy outcomes. The outcomes of interest were major bleeding, thromboembolism, and all-cause death. A total of 42 studies, including 3 randomized controlled trials, with 185 864 subjects were pooled. VKAs were associated with a significantly higher risk of major bleeding than either no anticoagulation (hazard ratio [HR], 1.47; 95% CI, 1.34-1.61) or DOACs (DOACs versus VKAs; HR, 0.74 [95% CI, 0.64-0.84]). For the prevention of thromboembolism, the efficacies of VKAs, DOACs, and no anticoagulation were equivalent. Nevertheless, dabigatran and rivaroxaban were associated with fewer embolic events. There were no differences in all-cause death with the administration of VKAs, DOACs, or no anticoagulation.

Conclusions: For dialysis-dependent populations, dabigatran and rivaroxaban were associated with better efficacy, while dabigatran and apixaban demonstrated better safety. No anticoagulation was a noninferior alterative, and VKAs were associated with the worst outcomes.

Keywords: anticoagulation; atrial fibrillation; chronic kidney disease; dialysis; meta‐analysis.

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Figures

Figure 1
Figure 1. Literature search.
Preferred Reporting Items for Systematic Reviews and Meta‐Analysis flow diagram illustrates the process for study inclusion. ESRD indicates end‐stage renal disease.
Figure 2
Figure 2. Summaries of the network meta‐analysis for the efficacy and safety assessment among patients receiving no anticoagulants, VKAs, and DOACs on the risk of (A) major bleeding, (B) thromboembolism, and (C) all‐cause death.
Left: network diagram; middle: forest plot. DOAC indicates direct oral anticoagulant; RR, relative risk; and VKA, vitamin K antagonist.
Figure 3
Figure 3. Summaries of the network meta‐analysis for the efficacy and safety assessment among patients receiving different DOACs on the risk of (A) major bleeding, (B) thromboembolism, and (C) all‐cause death.
Left: network diagram; middle: forest plot. CI indicates confidence interval; RR, relative risk; and VKA, vitamin K antagonist.
Figure 4
Figure 4. Summaries of the network meta‐analysis for the efficacy and safety assessment among patients receiving a different dose of apixaban on the risk of (A) major bleeding, (B) thromboembolism, and (C) all‐cause death.
Left: network diagram; middle: forest plot. RR indicates relative risk; and VKA, vitamin K antagonist.
Figure 5
Figure 5. Net clinical benefit of different anticoagulants that combined (A) and separated (B) different doses of apixaban.
RR indicates relative risk; and VKA, vitamin K antagonist.
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