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Abstract: FR-OR56

The Comparative Effectiveness and Safety of Direct Oral Anticoagulant (DOAC) and Warfarin Initiation in Adults with Atrial Fibrillation (AF) by eGFR Category

Session Information

Category: CKD (Non-Dialysis)

  • 2102 CKD (Non-Dialysis): Clinical, Outcomes, and Trials


  • Jun, Min, The George Institute for Global Health, Newtown, New South Wales, Australia
  • Gallagher, Martin P., The George Institute for Global Health, Newtown, New South Wales, Australia

Group or Team Name

  • KODIAC-AF Project Team

There is ongoing uncertainty regarding the risk-benefit ratio of DOACs in patients with AF and CKD.


We conducted an international multicenter cohort study(2011-2018) using healthcare data from 5 jurisdictions across Australia (666 participants of the 45 and Up Study [among 267153 recruited in 2006-09] with data linked to hospital/laboratory data [by CHeReL] and the Medicare Benefits Schedule and Pharmaceutical Benefits Scheme data provided by Services Australia; all linked data accessed via SURE) and Canada (73876 patients in AB,BC,MB,ON; record linkage of provincial administrative/laboratory data). We propensity score matched adults with a new dispensation of a DOAC (rivaroxaban, apixaban, dabigatran) or warfarin, who had AF and a recorded eGFR grouped as ≥60,45-59,30-44, <30ml/min/1.73m2. Chronic dialysis or kidney transplant recipients were excluded. We assessed 2 composite outcomes within 1 year of initiating either therapy: ischemic (all-cause death, ischemic stroke or TIA) and bleeding (intracranial, gastrointestinal or other). We used Cox regression to estimate the hazard ratios (HRs[95%CI]) of outcomes across eGFR categories and summarized centre data in random effects meta-analysis.


A total of 74542 eligible patients were included, among whom there were 6923(9.2%) ischemic and 1572(2.1%) bleeding events recorded. Across eGFR groups, DOAC initiation was associated with lower or similar risk for the ischemic outcome compared with warfarin initiation (pooled HRs[95%CI] for eGFR groups: 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). Similar results were observed for bleeding (0.75[0.65-0.86], 0.81[0.65-1.01], 0.82[0.66-1.02], 0.71[0.52-0.99], respectively). There was no evidence of heterogeneity across jurisdictions except for eGFR 45-59ml/min/1.73m2 for the ischemic outcome (I2=77%).


In this cohort of AF patients initiating DOAC or warfarin, compared to warfarin, DOAC use was associated with lower or similar risk of both ischemic and bleeding outcomes independent of eGFR. Our results suggest DOAC therapy may have a favourable risk-benefit ratio in AF patients with non-dialysis dependent CKD that is similar to that seen in AF patients with preserved kidney function. Adequately powered randomized trials are needed to confirm these findings.


  • Government Support – Non-U.S.