Efficacy and safety of non‐vitamin K antagonist oral anticoagulants versus warfarin in atrial fibrillation and kidney failure under hemodialysis: A meta‐analysis of controlled randomized trials

Background Atrial fibrillation (AF)‐related strokes are associated with disability and mortality. Stroke prevention with non‐vitamin K antagonist oral anticoagulants (NOACs) and vitamin K antagonists (VKAs) is the cornerstone of holistic management of AF. However, the safety and efficacy of NOACs in patients with AF on hemodialysis remain uncertain. This meta‐analysis aimed to evaluate currently available data to determine the potential utility of NOACs in AF patients with kidney failure receiving hemodialysis. Methods We searched the literature for randomized clinical trials comparing NOACs to VKA therapy in this population. Results About the Principal Efficacy Outcome, NOACs Did Not Decrease the Risk Compared to Warfarin (Relative Risk [RR] 0.79, 95% CI 0.45–1.37) while a Significant Heterogeneity Was Noted (p = 0.03). In the Valkyrie Study, Rivaroxaban Had better Cardiovascular Outcome than Warfarin (RR 0.57, 95% CI 0.43–0.75). For the Principal Safety Outcome, the Risk Was Similar between NOACs and Warfarin (RR 0.81, 95% CI 0.52–1.27) without Significant Heterogeneity (p = 0.11). The Pooled Event Rate of 3 Trials Disclosed a High Risk of all‐Cause Mortality (39.9% for NOACs, 34.6% for Warfarin) and Cardiovascular Mortality (10.1% for NOACs, 8.5% for Warfarin) for AF Patients with Kidney Failure Receiving Hemodialysis Even on Oral Anticoagulants. Conclusion Our results suggest that NOACs (rivaroxaban or apixaban) are as safe and effective as VKAs in patients with AF and kidney failure with hemodialysis. Even on oral anticoagulants, these patients remain at high risk of cardiovascular events and all‐cause mortality. Integrated care and holistic management are important for this high‐risk population.