Direct oral anticoagulants versus Vitamin K antagonist in kidney transplant recipients with atrial fibrillation: A study from a global federated research network

BACKGROUND: The risk-benefit profile of direct oral anticoagulants (DOACs) in kidney transplant recipients (KTRs) with atrial fibrillation (AF) remains under-investigated. PURPOSE: To evaluate the safety and efficacy of DOACs compared with vitamin K antagonists (VKAs) in KTRs with AF. METHODS: Retrospective analysis from TriNetX network. Adult KTRs with AF were included. Patients with mechanical valves, antiphospholipid syndrome, or an estimated eGFR <15 mL/min/1.73 m² were excluded. Anticoagulated patients were stratified into two cohorts (DOACs versus VKAs) . The first 3 months post-transplant were excluded, and follow-up for outcomes started at 9 months post-transplant and continued for 12 months thereafter. Propensity score matching (1:1) balanced baseline characteristics. The primary outcome was a composite of all-cause death, thromboembolic events, major bleeding. Secondary outcomes included each component of the composite outcome and kidney transplant rejection. RESULTS: Of the 1367 KTRs with AF, 695 received DOACs (65.0 ± 10.0 years, 30.5% female), while 672 received VKAs (64.0 ± 10.1 years, 29.9% female). After matching, each cohort included 553 patients. At one-year follow-up, compared with VKAs, DOACs were associated with a lower risk of the composite outcome (HR 0.66, 95%CI 0.50-0.87), and kidney transplant rejection (HR 0.46, 95%CI 0.30-0.71). A non-significant trend was observed toward a lower risk of all-cause death (HR 0.64, 95%CI 0.41-1.01), major bleeding (HR 0.66, 95%CI 0.43-1.01), thromboembolic events (HR 0.68, 95%CI 0.43-1.07). CONCLUSION: In this real-world cohort of KTRs with AF, DOACs use was associated with lower risk of the composite outcome and kidney transplant rejection.