Does rivaroxaban improve efficacy and safety compared to warfarin in adults with nonvalvular atrial fibrillation and stage 4 to 5 chronic kidney disease including dialysis?
Rivaroxaban may be associated with improved efficacy and safety compared with warfarin in patients with atrial fibrillation and advanced chronic kidney disease, though definitive recommendations require prospective randomized trials.
Background: Patients with atrial fibrillation (AF) and advanced chronic kidney disease (CKD) face elevated risks of stroke and bleeding; yet, optimal anticoagulation remains uncertain due to their exclusion from randomized trials. This systematic review and meta-analysis evaluated rivaroxaban vs warfarin in patients with AF and moderate-to-advanced CKD including dialysis. Methods: We searched PubMed/MEDLINE, Embase, and Cochrane CENTRAL through August 2025 for observational studies comparing rivaroxaban with warfarin in adults with nonvalvular AF and CKD stages 4 to 5 including dialysis. Primary outcomes were stroke/systemic embolism and major bleeding. Pooled hazard ratios (HRs) were calculated using random-effects models. Risk of bias was assessed using ROBINS-I, and certainty of evidence was evaluated using GRADE. Results: = .018). Favorable but nonsignificant trends were observed for intracranial hemorrhage (HR, 0.73; 95% CI, 0.49-1.08) and gastrointestinal bleeding (HR, 0.68; 95% CI, 0.46-1.03). Overall evidence quality was moderate according to GRADE assessment. Conclusion: In patients with AF and advanced CKD including dialysis, rivaroxaban may be associated with improved efficacy and safety compared with warfarin. However, heterogeneity in CKD stages and off-label dosing practices necessitate prospective randomized trials to establish definitive treatment recommendations.
Almajdi et al. (Sun,) studied this question.