Cardiovascular and renal outcomes in patients with atrial fibrillation and stage 4–5 chronic kidney disease receiving direct oral anticoagulants: a multicenter retrospective cohort study

The role of direct oral anticoagulants (DOAC) in patients with atrial fibrillation (AF) and stage 4–5 chronic kidney disease (CKD) is controversial. Electronic medical records from 2012 to 2021 were retrieved for patients with AF and stage 4–5 CKD receiving oral anticoagulants. Patients were separated into those receiving DOACs (dabigatran, rivaroxaban, apixaban, or edoxaban) or vitamin K antagonists (VKA). Primary outcomes included ischemic stroke (IS), systemic thrombosis (SE), major bleeding, gastrointestinal bleeding, hemorrhagic stroke, acute myocardial infarction, cardiovascular death, and all-cause death. Renal outcomes included eGFR declines, creatinine doubling, progression to dialysis, and major adverse kidney events (MAKE). The primary analysis was until the end of follow up and the results at 1-year and 2-year of follow ups were also assessed. 2,382 patients (DOAC = 1,047, VKA = 1,335) between 2012 and 2021 with AF and stage 4–5 CKD were identified. The mean follow-up period was 2.3 ± 2.1 years in DOCAs and 2.6 ± 2.3 years in VKA respectively. At the end of follow up, the DOAC patients had significantly decreased SE (subdistribution hazard ratio [SHR] = 0.50, 95% confidence interval [CI] = 0.34–0.73), composite of IS/SE (SHR = 0.78, 95% CI = 0.62–0.98), major bleeding (HR = 0.77, 95% CI = 0.66–0.90), hemorrhagic stroke (HR = 0.52, 95% CI = 0.36–0.76), and composite of bleeding events (SHR = 0.80, 95% CI = 0.69–0.92) compared with VKA patients. The IS efficacy outcome revealed neutral between DOAC and VKA patients (HR = 1.05, 95% CI = 0.79–1.39). In addition, DOAC patients had significantly decreased rates of eGFR decline > 50% (SHR = 0.75, 95% CI = 0.64–0.87), creatinine doubling (SHR = 0.80, 95% CI = 0.67–0.95), and MAKE (SHR = 0.81, 95% CI = 0.71–0.93). In patients with AF and stage 4–5 CKD, use of DOAC was associated with decreased rates of a composite of ischemic stroke/systemic embolism, a composite of bleeding events, and renal events compared to VKA. Efficacy and safety benefits associated with apixaban at standard doses were consistent throughout follow-up.