Abstract 15108: Apixaban versus Warfarin in Patients with Atrial Fibrillation and End-Stage Kidney Disease on Hemodialysis: A Propensity-Matched Real-World Analysis

Abstract

Introduction/Background: Patients with atrial fibrillation (AF) and end-stage kidney disease (ESKD) undergoing maintenance hemodialysis are at high risk for both thromboembolic and bleeding events. Comparative effectiveness and safety data for apixaban versus warfarin in this population remain limited. Research Question/Hypothesis: Among patients with AF and ESKD receiving hemodialysis, is apixaban associated with different thromboembolic and bleeding outcomes compared with warfarin? Methods/Approach: We performed a retrospective cohort study using the TriNetX Global Collaborative Network. Adult patients with AF and ESKD on maintenance hemodialysis receiving apixaban or warfarin between 2015 and 2026 were identified. Patients receiving alternative anticoagulants were excluded. Propensity score matching generated two balanced cohorts of 2,046 patients each. Outcomes were assessed from 7 days through 5 years following anticoagulation initiation. The primary efficacy outcome was a composite thromboembolic endpoint including cerebral embolism, transient ischemic attack, arterial embolism, and thrombosis. The primary safety outcome was major bleeding, defined as gastrointestinal or nontraumatic intracranial hemorrhage. Time-to-event analyses were performed using Kaplan-Meier methods. Results/Data: After matching, the mean age was 71.8 years, and 38.7% were female. Composite thromboembolic events occurred in 3.6% of patients receiving apixaban and in 5.1% of those receiving warfarin. Time-to-event analysis demonstrated no significant difference in thromboembolic risk (hazard ratio [HR] 0.84, 95% confidence interval [CI] 0.62-1.13; p=0.24). Major bleeding occurred in 4.7% versus 8.5% of patients and was significantly lower with apixaban (HR 0.65, 95% CI 0.51-0.83; p=0.001). Apixaban was also associated with lower gastrointestinal bleeding (HR 0.69, 95% CI 0.53-0.91; p=0.015), intracranial hemorrhage (HR 0.46, 95% CI 0.25-0.84; p=0.002), and arterial embolism (HR 0.57, 95% CI 0.34-0.95; p=0.03). Conclusions: Among patients with AF and ESKD receiving maintenance hemodialysis, apixaban was associated with significantly lower risks of major bleeding, gastrointestinal bleeding, intracranial hemorrhage, and arterial embolism compared with warfarin. No significant difference in overall thromboembolic risk was observed in time-to-event analysis. Prospective randomized studies are needed to further define the optimal anticoagulation strategy in this high-risk population