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(0x2fcfe80) 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) |
|---|---|---|---|---|
| *statistical heterogeneity I2 =63%; **statistical heterogeneity I2 =70% | ||||
| 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) |
The 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.
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