Kidney function and the comparative effectiveness and safety of direct oral anticoagulants versus warfarin in adults with atrial fibrillation: a multicenter observational study

Aims — The aim of this study was to determine the comparative effectiveness and safety of direct oral anticoagulants (DOACs) and warfarin in adults with atrial fibrillation (AF) by level of kidney function.

Methods and Results — We pooled findings from 5 retrospective cohorts (2011–2018) across Australia and Canada of adults with; a new dispensation for a DOAC or warfarin, an AF diagnosis, and a measure of baseline estimated glomerular filtration rate (eGFR). The outcomes of interest, within 1 year from the cohort entry date, were: (1) the composite of all-cause death, first hospitalization for ischemic stroke, or transient ischaemic attack (effectiveness), and (2) first hospitalization for major bleeding defined as an intracranial, upper or lower gastrointestinal, or other bleeding (safety). Cox models were used to examine the association of a DOAC versus warfarin with outcomes, after 1:1 matching via a propensity score. Kidney function was categorized as eGFR ≥60, 45-59, 30-44, and <30 mL/min/1.73m2. A total of 74,542 patients were included in the matched analysis. DOAC initiation was associated with greater or similar effectiveness compared to warfarin initiation across all eGFR categories (pooled HRs[95% CIs] for eGFR categories: 0.74[0.69-0.79], 0.76[0.54-1.07], 0.68[0.61-0.75] and 0.86[0.76-0.98]), respectively. DOAC initiation was associated with lower or similar risk of major bleeding than warfarin initiation (pooled HRs[95% CIs]: 0.75[0.65-0.86], 0.81[0.65-1.01], 0.82[0.66-1.02], and 0.71[0.52-0.99], respectively). Associations between DOAC initiation, compared with warfarin initiation, and study outcomes were not modified by eGFR category.

Conclusion — DOAC use, compared with warfarin use, was associated with lower or similar risk of all-cause death, ischemic stroke and transient ischemic attack and also a lower or similar risk of major bleeding across all levels of kidney function.