Comparison of outcomes of direct oral anticoagulants versus vitamin K antagonists for atrial fibrillation and chronic kidney disease: a systematic review and meta-analysis

Objective: To systematically evaluate the efficacy and safety of direct oral anticoagulants (DOAC) compared to vitamin K antagonists (VKA) for anticoagulation in patients with atrial fibrillation (AF) and chronic kidney disease (CKD). Methods: statistics employed to assess heterogeneity. Results: 16 studies were included in the analysis. Compared with VKA, DOAC can significantly reduced the risks of cardiovascular mortality (HR = 0.78; 95 %CI 0.70-0.87; P < 0.05), major bleeding (HR = 0.79; 95 %CI 0.64-0.97; P < 0.05), and intracranial hemorrhage (HR = 0.50; 95 %CI 0.37-0.66; P < 0.05). No significant differences were observed between the DOAC and VKA groups regarding all-cause death (HR = 0.98; 95 %CI 0.81-1.19; P = 0.82), stroke or systemic embolism (HR = 0.84; 95 %CI 0.68-1.04; P = 0.12), gastrointestinal bleeding (HR = 0.87; 95 %CI 0.61-1.24; P = 0.43), myocardial infarction (HR = 0.98; 95 %CI 0.78-1.23; P = 0.84), or stroke (HR = 0.85; 95 %CI 0.72-1.00; P = 0.06). Overall, DOACs demonstrated superior efficacy in reducing cardiovascular mortality, major bleeding, and intracranial hemorrhage. Among patients with end-stage renal disease, those treated with DOACs showed a tendency toward reduced major bleeding (HR = 0.58; 95 % CI 0.50-0.68; P < 0.05), gastrointestinal hemorrhage (HR = 0.65; 95 %CI 0.48-0.98 P < 0.05), and intracranial hemorrhage (HR = 0.56; 95 % CI, 0.38-0.82; P < 0.05). For patients without end-stage renal disease, the DOAC group had greater benefits in reducing the risks of all-cause death (HR = 0.91; 95 %CI 0.84-0.99; P = 0.03), cardiovascular mortality (HR = 0.77; 95 %CI 0.69-0.86; P < 0.05), major bleeding (HR = 0.85; 95 %CI 0.77-0.83; P < 0.05, and intracranial hemorrhage (HR = 0.42; 95 % CI, 0.28-0.65; P < 0.05). Conversely, the VKA group was more effective in reducing the risk of gastrointestinal hemorrhage events (HR = 1.38; 95 % CI 1.13-1.68; P < 0.05). Conclusion: In patients with non-valvular AF complicated by CKD, the use of DOAC is associated with a moderate reduction in the risks of cardiovascular mortality, major bleeding, and intracranial hemorrhage. Among patients with end-stage renal disease, DOACs offer more significant benefits in reducing the risks of major bleeding, gastrointestinal hemorrhage, and intracranial hemorrhage. For patients with non-end-stage renal disease, DOAC are associated with lower rates of all-cause death, cardiovascular mortality, major bleeding, and intracranial hemorrhage, whereas VKA are linked to an increased risk of gastrointestinal hemorrhage.