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. 2024 May 6;40(3):440-447.
doi: 10.1002/joa3.13051. eCollection 2024 Jun.

Meta-analysis evaluating apixaban in patients with atrial fibrillation and end-stage renal disease requiring dialysis

Ahmed AlTurki  1 , Mariam Marafi  2 , Ahmed Dawas  1 , Jacqueline Joza  1 , Riccardo Proietti  3 , Vincenzo Russo  4 , Thomas Mavrakanas  5 , Emilie Trinh  5 , Catherine Weber  5 , Rita Suri  5 , Vidal Essebag  1 , Thao Huynh  1
Affiliations

Meta-analysis evaluating apixaban in patients with atrial fibrillation and end-stage renal disease requiring dialysis

Ahmed AlTurki et al. J Arrhythm. .

Abstract

Background: Warfarin is considered the primary oral anticoagulant for patients with atrial fibrillation and end-stage renal disease (ESRD) requiring dialysis. Although warfarin can offer significant stroke prevention in this population, the accompanying major bleeding risks make warfarin nearly prohibitive. Apixaban was shown to be superior to warfarin in preventing stroke or systemic embolism, with a lower risk of bleeding and mortality in a large, randomized trial of individuals with mostly normal renal function but none with ESRD.

Methods: We systematically reviewed evidence comparing apixaban versus warfarin for atrial fibrillation in this population, and evaluated outcomes of stroke or systemic embolism, and major bleeding using random-effects models. The main safety outcome was major bleeding, and the main effectiveness outcome was stroke or systemic embolism.

Results: We found five observational studies of 10 036 patients (2638 receiving apixaban, and 7398 receiving warfarin) meeting inclusion criteria. Pooled analysis demonstrated a significant reduction in major bleeding with apixaban as compared to warfarin (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.42-0.61; p < .0001). Apixaban was also associated with a reduction in intracranial bleeding (OR 0.58, 95% CI 0.37-0.92; p = .02) and in gastrointestinal bleeding (OR 0.61, 95% CI 0.51-0.73; p < .0001). Furthermore, apixaban was associated with a reduction in stroke/systemic embolism (OR 0.64, 95% CI 0.50-0.82; p < .0001).

Conclusion: Apixaban was associated with superior outcomes and reduced adverse events compared to warfarin in observational studies of patients with atrial fibrillation on dialysis. Randomized controlled studies are needed to confirm these findings.

Keywords: anticoagulation; apixaban; atrial fibrillation; dialysis; warfarin.

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Conflict of interest statement

Dr. Mavrakanas reports personal fees from Daiichi Sankyo and Pfizer, outside the submitted work and received salary support from the Department of Medicine, McGill University, Montreal, Canada. Dr. Essebag has received honoraria from Bayer, Boehringer Ingelheim, BMS Pfizer, and Servier and is the recipient of a Clinical Research Scholar Award from the Fonds de recherche du Québec‐Santé (FRQS). Dr Huynh has received significant research grants from Boehringer Ingelheim Canada, Bristol Myers Squibb Canada, Pfizer Canada, and Bayer Canada. The other authors have no relevant disclosures. There was no funding provided for this study.

Figures

FIGURE 1
FIGURE 1
Risk of major bleeding in dialyzed patients with atrial fibrillation with apixaban versus warfarin.
FIGURE 2
FIGURE 2
Risk of gastrointestinal bleeding in dialyzed patients with atrial fibrillation with apixaban versus warfarin.
FIGURE 3
FIGURE 3
Risk of intracranial bleeding in dialyzed patients with atrial fibrillation with apixaban versus warfarin.
FIGURE 4
FIGURE 4
Risk of stroke or systemic embolism outcomes in dialyzed patients with atrial fibrillation apixaban versus warfarin.
FIGURE 5
FIGURE 5
Risk of all‐cause mortality in dialyzed patients with atrial fibrillation apixaban versus warfarin.
See this image and copyright information in PMC

References

    1. Olesen JB, Lip GYH, Kamper A‐L, Hommel K, Køber L, Lane DA, et al. Stroke and bleeding in atrial fibrillation with chronic kidney disease. N Engl J Med. 2012;367(7):625–635. - PubMed
    1. Bansal VK, Herzog CA, Sarnak MJ, Choi MJ, Mehta R, Jaar BG, et al. Oral anticoagulants to prevent stroke in nonvalvular atrial fibrillation in patients with CKD stage 5D: an NKF‐KDOQI controversies report. Am J Kidney Dis. 2017;70(6):859–868. - PubMed
    1. Kumar S, Lim E, Covic A, Verhamme P, Gale CP, Camm AJ, et al. Anticoagulation in concomitant chronic kidney disease and atrial fibrillation: JACC review topic of the week. J Am Coll Cardiol. 2019;74(17):2204–2215. - PubMed
    1. Cranenburg ECM, Schurgers LJ, Uiterwijk HH, Beulens JWJ, Dalmeijer GW, Westerhuis R, et al. Vitamin K intake and status are low in hemodialysis patients. Kidney Int. 2012;82(5):605–610. - PubMed
    1. Wizemann V, Tong L, Satayathum S, Disney A, Akiba T, Fissell RB, et al. Atrial fibrillation in hemodialysis patients: clinical features and associations with anticoagulant therapy. Kidney Int. 2010;77(12):1098–1106. - PubMed