The quality of evidence is downgraded by imprecise results (few outcome events and wide confidence intervals).
A Cochrane review [Abstract] 1 included 5 studies with a total of 12 545 subjects with atrial fibrillation (AF) and chronic kidney disease (CKD). The included studies compared direct oral anticoagulants (DOAC) (apixaban, dabigatran, edoxaban, and rivaroxaban) and dose-adjusted warfarin. Study duration ranged from 1.8 to 2.8 years. The large majority of participants included were CKD stage G3 (n=12 155), and a small number were stage G4 (n=390). CKD is classified into stage 1 (eGFR HASH(0x2fd8c80) 90 mL/min); stage 2 (60 to 89 mL/min); stage 3a (45 to 59 mL/min); stage 3b (30 to 44 mL/min); stage 4 (15 to 29 mL/min); and stage 5 (< 15 mL/min).
DOAC appeared to probably reduce the incidence of stroke and systemic embolism events compared to warfarin (table T1). No difference was observed in myocardial infarction and all-cause mortality. There were no statistically significant differences in major bleeding, minor bleeding, gastrointestinal bleeding, or intracranial haemorrhage.
| Outcome | Relative effect (95% CI) | Assumed risk - Warfarin | Corresponding risk - DOAC (95% CI) | Participants (studies) |
|---|---|---|---|---|
| All strokes andsystemic embolic events | RR 0.81 (0.65 to 1.00) | 29 per 1000 | 23 per 1000(19 to 29) | 12 545 (5) |
| Myocardial infarction | RR 0.92 (0.45 to 1.90) | 11 per 1000 | 10 per 1000(5 to 21) | 2 740 (1) |
| All-cause mortality | RR 0.91 (0.78 to 1.05) | 78 per 1000 | 71 per 1000(61 to 82) | 9 595 (4) |
| Major bleeding | RR 0.79 (0.59 to 1.04)* | 55 per 1000 | 43 per 1000(32 to 57) | 12 521 (5) |
| Minor bleeding | RR 0.97(0.58 to 1.61)** | 74 per 1000 | 72 per 1000(43 to 119) | 3 012 (2) |
| Gastrointestinal bleeding | RR 1.40(0.97 to 2.01) | 17 per 1000 | 24 per 1000(17 to 35) | 5 678 (2) |
| Intracranial haemorrhage | RR 0.43 (0.27 to 0.69) | 14 per 1000 | 6 per 1000(4 to 9) | 12 521 (5) |
| *statistical heterogeneity I2 =63%; **statistical heterogeneity I2 =70% | ||||
Clinical comments
NoteThe results chiefly reflect CKD stage G3. Application of the results to CKD stage G4 patients requires additional investigation, and CKD stage G5 patients could not be assessed. Date of latest search: References
Primary/Secondary Keywords
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