Apixaban vs Warfarin in Hemodialysis: Lower Stroke and Bleeding Rates in New AF

Initiating apixaban rather than warfarin soon after a new diagnosis of atrial fibrillation (AF) was associated with lower rates of ischemic stroke and clinically important bleeding in patients with kidney failure on hemodialysis, according to a target trial emulation published in the American Journal of Kidney Diseases.

The investigators noted that AF affects more than a quarter of patients receiving hemodialysis, who are at high risk of ischemic stroke, and that oral anticoagulation may reduce this risk at the expense of excess bleeding.

Using US Renal Data System data, the researchers emulated a randomized trial among Medicare-insured patients on hemodialysis who were newly diagnosed with AF from 2014 to 2019 and had no recent oral anticoagulant use. Using propensity score matching, they paired  3,978 patients who initiated apixaban within 30 days of diagnosis with 3,978 who initiated warfarin; the median CHA₂DS₂-VASc score was 4. In intention-to-treat analyses with up to 1 year of follow-up, apixaban was associated with a 34% relative reduction in ischemic stroke (hazard ratio, 0.66; 95% CI, 0.47-0.94) and a 28% relative reduction in clinically important bleeding (hazard ratio, 0.72; 95% CI, 0.63-0.83).

All-cause mortality did not differ between groups, nor did the negative control outcomes of hip fracture and pneumonia. Results were consistent when the analysis was restricted to patients with a CHA₂DS₂-VASc score of 2 or higher or to those whose initial apixaban dose matched label recommendations. Apixaban was prescribed at 2.5mg twice daily in 57.2% of users and 5mg twice daily in 42.8%. Treatment persistence was limited, with median use of 58 days for apixaban and 93 days for warfarin.

The authors noted that residual confounding remains possible in an observational analysis, that adherence to the initial treatment was low, that international normalized ratio data were unavailable for warfarin users, and that the findings reflect US prescribing practices. They concluded that the results support apixaban as the preferred anticoagulant in this clinical situation.

Source: Winkelmayer WC, Montez-Rath ME, He M, et al. Initiation of apixaban versus warfarin in patients with kidney failure on hemodialysis with newly diagnosed atrial fibrillation: a target trial emulation. Am J Kidney Dis. Published online October 20, 2026. doi:10.1053/j.ajkd.2026.08.009