Comparative Efficacy and Safety of DOACs for Stroke Events Prevention in Patients with Atrial Fibrillation on Dialysis: a Systematic Review and Meta-analysis

Introduction:

While DOACs are widely used in the general population, their efficacy and safety in patients on dialysis remain poorly studied. We conducted an updated systematic review to evaluate the relative efficacy and safety of DOACs in atrial fibrillation (AF) patients on dialysis.

Material and method:

We followed Cochrane and PRISMA guidelines. A comprehensive literature search was conducted in PubMed, Embase, and Cochrane Library to identify studies evaluating DOACs administration in AF patients on dialysis. Eligible studies included RCTs and observational studies comparing DOACs administration to warfarin. The primary efficacy outcome was stroke while bleeding and mortality events were defined as safety outcomes. We performed subgroup analysis and meta-regression by the DOACs type. Sensitivity analysis evaluated the influence of low-quality studies on the primary outcome. Pooled Odds Ratio (OR) and 95% Confidence Interval (CI) were calculated using random-effects models. We use the Comprehensive Meta-Analysis software to calculate outcomes.

Results and discussion:

Our study included 52,407 patients from 16 studies (4 RCTs and 12 observational studies). DOACs were associated with a significantly reduced risk of stroke, bleeding events, and mortality in patients with AF on dialysis compared to warfarin (OR 0.82, 95% CI: 0.69–0.98, based on 11 studies; OR 0.63, 95% CI: 0.48–0.84, n=12; and OR 0.87, 95% CI: 0.77–0.99, n=8, respectively). In sub-group analysis, apixaban was associated with a lower risk for stroke and bleeding compared to warfarin (OR 0.83, 95% CI: 0.70–1.00 and OR 0.87, 95% CI: 0.77–0.99, respectively). Meta-regression analysis found a statistically significant association between apixaban use versus warfarin and a decreased risk for bleeding (R² = 0.43).

Conclusion:

The most updated meta-analysis supports DOACs, and particularly apixaban, as an effective alternative to warfarin for stroke prevention with a reduced risk for bleeding and mortality in atrial fibrillation patients on dialysis.