Anticoagulation for Patients With Concomitant Atrial Fibrillation and End-Stage Renal Disease: A Systematic Review and Network Meta-Analysis.
For people on dialysis with atrial fibrillation, warfarin-type drugs caused the most major bleeding, while newer direct anticoagulants bled less; no drug clearly reduced deaths compared with no anticoagulation.
Background
Atrial fibrillation with end-stage kidney disease is common and carries a poor prognosis, and the role of oral anticoagulation in patients on long-term dialysis remains debated.
Study design
Updated network meta-analysis of MEDLINE, EMBASE and Cochrane studies to December 2022, comparing dabigatran, rivaroxaban, apixaban (2.5/5 mg twice daily), VKAs and no anticoagulation. 42 studies, including 3 RCTs, with 185,864 subjects.
Key findings
VKAs had higher major bleeding than no anticoagulation (HR 1.47, 95% CI 1.34-1.61) and than DOACs (DOACs vs VKAs HR 0.74, 95% CI 0.64-0.84). Thromboembolism prevention was equivalent across VKAs, DOACs and no anticoagulation, though dabigatran and rivaroxaban were associated with fewer embolic events. All-cause death did not differ.
Clinical implications
Dabigatran and rivaroxaban showed better efficacy and dabigatran and apixaban better safety; VKAs were associated with the worst outcomes, supporting individualized decisions rather than routine warfarin in dialysis patients.
Category
Research
Source
Journal of the American Heart Association
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