Apixaban vs Warfarin in AF With Advanced CKD

Apixaban use was associated with lower risks of major bleeding and ischemic stroke than warfarin among patients with atrial fibrillation and stage 4 or 5 chronic kidney disease who were not receiving dialysis, according to a retrospective cohort study in JAMA Network Open.

Investigators used Medicare and Optum claims in a 3-group target-trial emulation. The analysis included 14,712 new apixaban users, 6,335 new warfarin users, and 21,005 people who did not initiate oral anticoagulation. Mean age was approximately 77 to 80 years across groups.

Compared with no anticoagulant use, apixaban was associated with more major bleeding (hazard ratio [HR], 1.32; 95% CI, 1.11-1.58) but fewer ischemic strokes (HR, 0.46; 95% CI, 0.32-0.66). Warfarin was associated with more major bleeding than nonuse (HR, 2.44; 95% CI, 2.06-2.88) without a statistically significant difference in ischemic stroke.

In the direct comparison, apixaban was associated with lower risks of major bleeding (HR, 0.55; 95% CI, 0.46-0.65) and ischemic stroke (HR, 0.50; 95% CI, 0.33-0.78) than warfarin.

The authors cautioned that stroke events were relatively few, median follow-up was shorter than 6 months, and residual confounding is possible in claims data. The results do not establish causation and may not generalize to uninsured patients, and other direct oral anticoagulants were not evaluated.

Source: Chen Q, Singer DE, Fu EL, et al. Oral anticoagulants in patients with atrial fibrillation and advanced CKD not requiring dialysis. JAMA Netw Open. 2026;9(9):e2632225. doi:10.1001/jamanetworkopen.2026.32225