What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Atrial Fibrillation and End-Stage Kidney Disease (n=44863). Intervention: Direct oral anticoagulants (DOACs) vs. Vitamin K antagonists (VKAs). Primary outcome: Stroke or systemic embolism (RR 0.93, 95% CI 0.77-1.14).

April 2, 2024Open Access

Comparison of Effectiveness and Safety of Direct-Acting Oral Anticoagulants and Vitamin K Agonists in Patients With Atrial Fibrillation and End-Stage Kidney Disease: A Systematic Review and Meta-Analysis

Key Result

Direct oral anticoagulants showed no significant difference in stroke or systemic embolism (RR 0.93) but reduced major bleeding by 16% compared to vitamin K antagonists in patients with AF and ESRD.

Study Design

Type

Meta-Analysis (n=44,863)

Structured PICO

Do direct oral anticoagulants reduce stroke, mortality, or major bleeding compared to vitamin K antagonists in patients with atrial fibrillation and end-stage kidney disease?

Population

44,863 patients with atrial fibrillation (AF) and end-stage renal disease (ESRD) (GFR < 15 mL/min/1.73 m2) pooled from 11 studies (3 RCTs, 8 observational).

Intervention

Direct oral anticoagulants (DOACs) including apixaban, rivaroxaban, and dabigatran

Comparator

Vitamin K antagonists (VKAs) / warfarin

Outcome

Stroke or systemic embolismhard clinical

In patients with atrial fibrillation and end-stage renal disease, DOACs offer comparable efficacy for stroke prevention and a significantly lower risk of major bleeding compared to vitamin K antagonists.

Main Result

Effect estimate: RR 0.93 (95% CI 0.77-1.14)

Limitations

Majority of included studies adopted an observational design
Variability in endpoint definitions
Use of different DOAC formulations with varied dosages
Heterogeneous inclusion and exclusion criteria
Retrospective studies faced challenges in accurately identifying patients receiving concomitant antiplatelet therapy

Abstract

The objective of the study is mentioned, but it could be further clarified by explicitly stating the aim to compare the effectiveness and safety of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) specifically in patients with atrial fibrillation (AF) and end-stage renal disease (ESRD). We conducted a thorough electronic search of the literature, encompassing databases such as PubMed, EMBASE, Cochrane Library, and Web of Science from their inception up to March 5, 2024. Furthermore, we meticulously examined the bibliographies of included studies to identify additional relevant literature. The reporting of this meta-analysis adhered to the guidelines outlined in the Preferred Reporting of Systematic Review and Meta-analysis guidelines. The endpoints evaluated in this meta-analysis included all-cause mortality, stroke or systemic embolism, and major bleeding. Data analysis was carried out utilizing RevMan Version 5.4 (Cochrane, London, United Kingdom). Dichotomous outcomes, including all-cause mortality, stroke or systemic embolism, and major bleeding, were presented as risk ratios (RRs) with corresponding 95% confidence intervals (CI). A total of 11 studies were incorporated in this meta-analysis, comprising a pooled sample size of 44,863 participants with AF. The pooled analysis revealed no significant disparity between DOACs and VKAs concerning stroke or systemic embolism (RR: 0.93, 95% CI: 0.77 to 1.14) and all-cause mortality (RR: 0.86, 95% CI: 0.74 to 1.00). However, there was a noteworthy reduction in the risk of major bleeding events associated with DOACs compared to VKAs (RR: 0.84, 95% CI: 0.73 to 0.96). Consequently, DOACs may be considered a viable alternative to warfarin in patients with ESRD. However, we need further larger clinical trials to validate these findings.

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