Apixaban May Be Preferred Anticoagulant in AF With Advanced CKD: JAMA
A new study published in the Journal of American Medical Association showed that anticoagulation was linked to a decreased risk of ischemic stroke but an increased risk of bleeding in individuals with atrial fibrillation and severe chronic renal disease who are not on dialysis.
In patients with severe chronic kidney disease (CKD) and atrial fibrillation (AF) who are not getting dialysis, the overall benefit of oral anticoagulants (OACs) is still unknown. The purpose of this trial was to evaluate the estimated safety and efficacy of apixaban with warfarin and no OAC usage in patients with advanced CKD with AF who are not undergoing dialysis.
Patients from Medicare fee-for-service claims (January 1, 2013, to December 31, 2022) and the Optum deidentified Clinformatics Data Mart database (January 1, 2013, to February 28, 2025) were included in this retrospective cohort analysis, which employed a three-group target trial emulation approach. Participants with AF, CKD stage 4 or 5, no history of dialysis, and ongoing pharmaceutical and medical coverage were eligible. The period of data analysis was February 2025–June 2026. Hospitalization for significant bleeding, ischemic stroke, and their combination were the main outcomes. Weighted hazard ratios (HRs) and rate differences (RDs) per 1000 person-years (PYs) were calculated after baseline characteristics were balanced using propensity score matching weights.
With mean ages of 78.93, 77.47, and 79.59 years, respectively, the research comprised 14,712 apixaban users, 6,335 warfarin users, and 21,005 nonusers of oral anticoagulants (OACs). Apixaban was linked to a decreased risk of ischemic stroke (HR, 0.46; 95% CI, 0.32–0.66) but a greater risk of serious bleeding (HR, 1.32; 95% CI, 1.11–1.58) when compared to OAC nonusers.
The composite outcome (HR, 1.05; 95% CI, 0.89–1.22) did not vary significantly. Warfarin raised the composite outcome (HR, 1.95; 95% CI, 1.69–2.26) and was linked to a considerably greater risk of serious bleeding (HR, 2.44; 95% CI, 2.06–2.88) without significantly lowering ischemic stroke. Apixaban decreased the risk of significant bleeding and ischemic stroke when compared to warfarin.
Overall, apixaban was linked to lower ischemic stroke and higher major bleeding than nonuse in this large retrospective cohort study using two national US databases, while warfarin was linked to higher major bleeding and no significant decrease in ischemic stroke among patients with AF and CKD stage 4 or 5 who were not receiving dialysis. Apixaban was linked to decreased incidence of severe bleeding and ischemic stroke when compared to warfarin. Apixaban was further favored over nonuse by tipping-point analyses.
Source:
Chen, Q., Singer, D. E., Fu, E. L., Yang, C.-T., Pritchard, K., Desai, R. J., & Lin, K. J. (2026). Oral anticoagulants in patients with atrial fibrillation and advanced CKD not requiring dialysis. JAMA Network Open, 9(9), e2632225. https://doi.org/10.1001/jamanetworkopen.2026.32225
