What does this research mean for the field?

In patients with end-stage kidney disease and atrial fibrillation, direct oral anticoagulants reduce the risk of ischemic stroke/systemic embolism more than warfarin and have a lower risk of major bleeding. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

January 10, 2026The Korean Journal of Internal Medicine0 citationsOpen Access

Comparative efficacy and safety of warfarin and direct oral anticoagulants in patients with end-stage kidney disease and atrial fibrillation

YYYujin YangChungnam National University Hospital SLSun Hwa LeeEwha Womans University WHWonmook HwangSejong General Hospital

Key Result

In patients with ESKD and AF, DOACs reduced ischemic stroke/systemic embolism risk more than warfarin and had a lower major bleeding risk (aHR 0.51).

Key Points

This study aims to evaluate the efficacy and safety of warfarin and direct oral anticoagulants in patients with end-stage kidney disease and atrial fibrillation.
Conducted a multicenter retrospective analysis of 933 patients with ESKD and nonvalvular AF.
Patients grouped based on initial treatment: no anticoagulation, warfarin, or DOACs.
Primary outcomes assessed included ischemic stroke or systemic embolism (IS/SE) and major bleeding (MB).
Used inverse probability of treatment weighting to adjust for confounding factors.
Both warfarin and DOACs significantly reduced IS/SE risk compared to no anticoagulation.
Warfarin increased MB risk compared to no anticoagulation, with a higher risk of intracranial and gastrointestinal bleeding.
DOACs also elevated MB risk compared to no anticoagulation, mainly due to intracranial hemorrhage.
DOACs showed a lower MB risk than warfarin, making them potentially more suitable for this high-risk group.
Both anticoagulant options reduced all-cause mortality relative to no treatment.

Structured PICO

Do warfarin and DOACs reduce ischemic stroke or systemic embolism compared to no anticoagulation in patients with end-stage kidney disease and atrial fibrillation?

Population

933 Korean patients with end-stage kidney disease (ESKD) on dialysis and nonvalvular atrial fibrillation (AF). Exclusion criteria: moderate to severe mitral stenosis, mechanical prosthetic valve, other conditions requiring anticoagulation, not receiving dialysis, and prescription of oral anticoagulants for less than 1 month.

Intervention

Direct oral anticoagulants (DOACs: apixaban, rivaroxaban, edoxaban, or dabigatran; n=132) or Warfarin (n=197)

Comparator

No anticoagulation (n=604)

Outcome

Ischemic stroke or systemic embolism (IS/SE) as primary efficacy outcome; Major bleeding (MB) as primary safety outcome, truncated at 2 years of follow-upcomposite

In patients with end-stage kidney disease and atrial fibrillation, DOACs provide similar stroke prevention to warfarin but with a significantly lower risk of major bleeding, making them a preferable anticoagulant option.

Main Result

Absolute Event Rate: 0% vs 0%

Abstract

Background/Aims: Patients with atrial fibrillation (AF) and end-stage kidney disease (ESKD) require careful anticoagulation because thrombotic and bleeding risks are both elevated. We evaluated the efficacy and safety of warfarin, direct oral anticoagulants (DOACs), and no anticoagulation in Korean patients with ESKD and AF.Methods: In this multicenter retrospective study, we included 933 patients with ESKD and nonvalvular AF treated between 2010 and 2023. Patients were assigned to three groups by initial treatment: no anticoagulation (n = 604), warfarin (n = 197), or DOACs (n = 132). The primary efficacy outcome was ischemic stroke or systemic embolism (IS/SE); the primary safety outcome was major bleeding (MB). Secondary outcomes were intracranial hemorrhage (ICH), gastrointestinal bleeding (GIB), and all-cause mortality. Inverse probability of treatment weighting was used to adjust for confounding.Results: Both warfarin (adjusted hazard ratio aHR, 0.55) and DOACs (aHR, 0.36) significantly reduced the risk of IS/SE compared with no anticoagulation. However, warfarin increased MB risk compared with no anticoagulation (aHR, 2.69), including ICH and GIB. DOACs also increased MB risk versus no anticoagulation (aHR, 1.37), driven primarily by ICH. Compared with warfarin, DOACs showed a lower MB risk (aHR, 0.51). Both warfarin and DOACs reduced all-cause mortality relative to no anticoagulation (aHR, 0.53 and 0.57, respectively).Conclusions: Among Korean patients with ESKD and AF, both warfarin and DOACs reduced IS/SE but increased MB. Given their lower MB risk than warfarin, DOACs may be preferable for anticoagulation in this high-risk population.

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