Apixaban vs. warfarin for venous thromboembolism in renal impairment: a meta-analysis of efficacy and safety

Abstract Background Patients with chronic kidney disease (CKD) are at increased risk for venous thromboembolism (VTE) and bleeding, making anticoagulation challenging. The safety and effectiveness of apixaban compared to warfarin in CKD patients with acute VTE are not well-established. Purpose We conducted a systematic review and meta-analysis to evaluate the effectiveness and safety of apixaban versus warfarin in patients with CKD or end-stage renal disease (ESRD) and newly diagnosed VTE. Methods PubMed, Scopus, and Cochrane were systematically searched from inception through February 2025 for randomized controlled trials (RCTs), observational studies, and post-hoc analyses comparing apixaban with warfarin in VTE treatment among CKD patients. Results Four retrospective cohort studies involving 54,689 patients (38,029 on warfarin, 16,660 on apixaban) were included. The mean age was 59–75 years, and 30,043 were female. Of these, 24,129 were on dialysis. Common comorbidities included heart failure, diabetes, and cerebrovascular disease. The follow-up period was 6 months. Apixaban doses used were 10 mg, 5 mg, and 2.5 mg. Apixaban was associated with a significantly lower risk of recurrent VTE (HR 0.78 95% CI: 0.64–0.94) and major bleeding (HR 0.78 95% CI: 0.71–0.86) compared to warfarin. There was no significant difference in all-cause mortality (HR 1.05 95% CI: 0.96–1.14). These results remained consistent across subgroup analyses, including clinically relevant non-major bleeding, GI bleeding, intracranial bleeding, and dialysis patients. Conclusion Apixaban may be more effective and safer than warfarin for VTE treatment in CKD patients. Further RCTs are needed to confirm these findings.Primary Endpoints Secondary Endpoints