Apixaban in End-Stage Kidney Disease

Study Questions:

Can apixaban be used safely in patients with atrial fibrillation (AF) and end-stage kidney disease (ESKD) on dialysis?


In this retrospective cohort study, 25,523 patients (mean age 68.2 years) with dialysis-dependent ESKD and AF treated with warfarin (n = 23,172) or apixaban (n = 2,351) were identified by analysis of a national renal disease registry. Outcomes were compared between cohorts of apixaban and warfarin patients that were matched based on prognostic score at a ratio of 1:3.


Standard-dose apixaban (5 mg twice daily) was associated with a significantly lower risk of stroke/embolism compared to low-dose apixaban (2.5 mg twice daily; hazard ratio [HR], 0.61) and warfarin (HR, 0.64). Standard-dose apixaban also was associated with a significantly lower risk of death (HR, 0.64 compared to low-dose apixaban and 0.63 compared to warfarin). Compared to warfarin, apixaban was associated with a significantly lower risk of major bleeding (HR, 0.72).


Standard-dose apixaban is both safer and more effective than warfarin for stroke prevention in dialysis-dependent patients with AF.


The large-scale randomized clinical trials that led to approval of dabigatran, rivaroxaban, and apixaban for stroke prevention in AF patients in the United States all excluded patients with ESKD and therefore provided no data on safety/efficacy in this subgroup of patients. The off-label use of dabigatran and rivaroxaban has been associated with poor outcomes in ESKD patients. Apixaban is less dependent on renal excretion, and based on pharmacokinetic data, current labeling recommends standard-dose apixaban in dialysis patients. Until now, however, there have been no data on clinical outcomes. This important study for the first time provides solid evidence supporting the use of standard-dose apixaban in dialysis-dependent AF patients.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Embolism, Hemorrhage, Kidney Failure, Chronic, Primary Prevention, Renal Dialysis, Stroke, Vascular Diseases, Warfarin

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