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Comparative Outcomes of Apixaban and Acenocoumarol in Advanced Chronic Kidney Disease and Atrial Fibrillation: A
Ioana Livia Suliman1,2, Liliana-Ana Tuta1,2, Florin Gabriel Panculescu1,2
1Faculty of Medicine, "Ovidius" University of Constanta, 900470 Constanta, Romania.
Insights
Apixaban significantly reduced bleeding events compared to acenocoumarol in patients with advanced chronic kidney disease and atrial fibrillation. This study suggests apixaban is a safer anticoagulant option for this high-risk population, including those on dialysis.
Area of Science:
- Nephrology
- Cardiology
- Hematology
Background:
- Anticoagulation in advanced chronic kidney disease (CKD) and atrial fibrillation (AF) presents challenges due to high risks of thrombosis and bleeding.
- Limited evidence compares direct oral anticoagulants (DOACs) like apixaban with vitamin K antagonists (VKAs) like acenocoumarol in this specific patient group, especially those on dialysis.
- Endothelial dysfunction, uremic inflammation, and impaired hemostasis contribute to the complexity of managing anticoagulation in CKD patients.
Purpose of the Study:
- To compare the safety and efficacy of apixaban versus acenocoumarol in patients with advanced CKD (stages 4-5) and AF.
- To evaluate bleeding and thromboembolic event rates in patients receiving apixaban or acenocoumarol.
- To assess the performance of apixaban in dialysis patients with CKD and AF.
Main Methods:
- A single-center, retrospective observational study included 93 patients with CKD stages 4-5 and AF.
- Patients received either apixaban (n=50) or acenocoumarol (n=43) between January 2021 and February 2025.
- Bleeding events were classified using ISTH criteria; statistical analyses included t-tests and chi-squared tests.
Main Results:
- The overall bleeding rate was significantly lower in the apixaban group (16.0%) compared to the acenocoumarol group (53.5%; p=0.01).
- No thromboembolic events were observed in either treatment group.
- Dialysis patients exhibited higher overall bleeding rates, particularly those on VKAs.
Conclusions:
- Apixaban demonstrated comparable thromboembolic protection to acenocoumarol with a significantly lower incidence of bleeding events in advanced CKD patients with AF.
- Apixaban appears to be a safer and more practical anticoagulant choice for this high-risk population, including those undergoing dialysis.
- Further multicenter prospective studies are recommended to validate these findings.
Abstract:
Background: Anticoagulation in patients with advanced chronic kidney disease (CKD) and atrial fibrillation (AF) remains challenging due to the concurrent risks of thrombosis and bleeding driven by endothelial dysfunction, uremic inflammation, and impaired hemostasis. Evidence comparing vitamin K antagonists (VKAs) with direct oral anticoagulants (NOACs) in this high-risk population, particularly in dialysis, is still limited. Methods: We conducted a single-center, retrospective observational study including 93 patients with CKD stages 4-5 and AF treated between January 2021 and February 2025. Fifty patients received apixaban (2.5-5 mg twice daily), and forty-three received acenocoumarol with a target INR of 2.0-3.0. Thirty-eight patients (41%) were on maintenance hemodialysis. Demographics, comorbidities, and risk scores (CHA2DS2-VASc and HAS-BLED) were analyzed. Bleeding events were classified per ISTH criteria. Statistical comparisons used t-tests and χ2 tests, with p < 0.05 considered significant. Results: The mean age was 67.8 ± 9.1 years, and 51.6% were male. Major bleeding occurred in 9.7%, minor in 15.8%, and overdose-related bleeding in 10.0% of patients. The overall bleeding rate was significantly lower in the apixaban group (16.0%) than in the acenocoumarol group (53.5%; p = 0.01). No thromboembolic events were observed in either group. Dialysis patients had higher bleeding rates overall (13.2% vs. 7.4%), mainly among those on VKAs. The HAS-BLED score moderately correlated with bleeding incidence (r = 0.43, p < 0.01). Conclusions: Apixaban provided comparable thromboembolic protection with significantly fewer bleeding events than acenocoumarol, including in patients on dialysis. These findings support apixaban as a safer and more practical anticoagulant option in advanced CKD, consistent with its limited renal clearance and reduced influence on the inflammation-coagulation axis. Further multicenter prospective studies are warranted to validate these real-world results.
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