Direct oral anticoagulants versus vitamin K antagonists in patients with atrial fibrillation and stage 5 chronic kidney disease under dialysis: A systematic review and meta-analysis of randomized controlled trials

Background In patients with atrial fibrillation (AF) and normal or slightly impaired renal function, the use of direct oral anticoagulants (DOACs) is preferable to vitamin K antagonists (VKAs). However, in patients undergoing hemodialysis, the efficacy, and safety of DOACs compared with VKAs are sti...

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Bibliographic Details
Published in:Journal of thrombosis and thrombolysis 2024-03, Vol.57 (3), p.381-389
Main Authors: de Lucena, Larissa A., Freitas, Marcos A. A., Souza, Ana K. C., Silva, Caroliny H. A., Watanabe, Janine M. F., Guedes, Felipe L., Almeida, Jose B., de Oliveira, Rodrigo A.
Format: Article
Language:English
Subjects:
Administration, Oral
Antagonists
Anticoagulants
Anticoagulants - therapeutic use
Atrial Fibrillation - complications
Bleeding
Cardiac arrhythmia
Cardiology
Cardiovascular diseases
Clinical trials
Fibrillation
Fibrinolytic Agents - therapeutic use
Hematology
Hemodialysis
Hemorrhage - chemically induced
Hemorrhage - drug therapy
Humans
Ischemia
Kidney diseases
Kidney Failure, Chronic - complications
Medicine
Medicine & Public Health
Meta-analysis
Mortality
Randomized Controlled Trials as Topic
Renal Dialysis - adverse effects
Renal function
Statistical analysis
Statistics
Stroke
Stroke - etiology
Vitamin K
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Summary:Background In patients with atrial fibrillation (AF) and normal or slightly impaired renal function, the use of direct oral anticoagulants (DOACs) is preferable to vitamin K antagonists (VKAs). However, in patients undergoing hemodialysis, the efficacy, and safety of DOACs compared with VKAs are still unknown. Purpose To review current evidence about the safety and efficacy of DOACs compared to VKAs, in patients with AF and chronic kidney disease under hemodialysis. Methods We systematically searched PubMed, Scopus, and Cochrane databases for RCTs comparing DOACs with VKAs for anticoagulation in patients with AF on dialysis therapy. Outcomes of interest were: (1) stroke; (2) major bleeding; (3) cardiovascular mortality; and (4) all-cause mortality. Statistical analysis was performed using RevMan 5.1.7 and heterogeneity was assessed by I 2 statistics. Results Three randomized controlled trials were included, comprising a total of 383 patients. Of these, 218 received DOACs (130 received apixaban; 88 received rivaroxaban), and 165 were treated with VKAs (116 received warfarin; 49 received phenprocoumon). The incidence of stroke was significantly lower in patients treated with DOACs (4.7%) compared with those using VKAs (9.5%) (RR 0.42; 95% CI 0.18–0.97; p  = 0.04; I 2  = 0%). However, the difference was not statistically significant in the case of ischemic stroke specifically (RR 0.42; 95% CI 0.17–1.04; p  = 0.06; I 2  = 0%). As for the major bleeding outcome, the DOAC group (11%) had fewer events than the VKA group (13.9%) but without statistical significance (RR 0.75; 95% CI 0.45–1.28; p  = 0.29; I 2  = 0%). There was no significant difference between groups regarding cardiovascular mortality (RR 1.23; 95% CI 0.66–2.29; p  = 0.52; I 2  = 13%) and all-cause mortality (RR 0.98; 95% CI 0.77–1.24; p  = 0.84; I 2  = 16%). Conclusion This meta-analysis suggests that in patients with AF on dialysis, the use of DOACs was associated with a significant reduction in stroke, and a numerical trend of less incidence of major bleeding compared with VKAs, but in this case with no statistical significance. Results may be limited by a small sample size or insufficient statistical power.
ISSN:1573-742X
0929-5305
1573-742X
DOI:10.1007/s11239-023-02945-0