Direct Oral Anticoagulants Exhibit Lower Risks of Mortality and Bleeding Compared to Vitamin K Antagonists in Atrial Fibrillation Patients on Chronic Hemodialysis: A Systematic Review and Meta-Analysis

This meta-analysis aimed to assess the outcomes of patients with atrial fibrillation undergoing chronic hemodialysis, comparing the effectiveness of direct oral anticoagulants (DOACs) and vitamin K antagonists. A systematic search was conducted across various databases including PubMed, Embase, and Google Scholar. Efficacy outcomes focused on the risk of stroke and mortality, whereas safety outcomes assessed the risk of bleeding. Review Manager generated forest plots for data synthesis. Statistical significance was set at P < 0.05, and random-effects models were used. Subgroup analysis identified the sources of heterogeneity. Nine studies met the inclusion criteria for the final analysis. The risk of all-cause stroke [risk ratio (RR): 0.64; 95% confidence interval (CI): 0.51–0.81; P = 0.0001; I 2 = 0%], ischemic stroke (RR: 0.53; 95% CI: 0.29–0.96; P = 0.04; I 2 = 0%), all-cause mortality (RR: 0.73; 95% CI: 0.60–0.88; P = 0.001; I 2 = 71%), major bleeding (RR: 0.63; 95% CI: 0.52–0.76; P < 0.00001; I 2 = 44%), gastrointestinal bleeding (RR: 0.67; 95% CI: 0.53-0.85; P = 0.0009; I 2 = 36%), intracranial hemorrhage (RR: 0.57; 95% CI: 0.38–0.84; P = 0.004; I 2 = 0%) were lower in the DOAC group compared with the vitamin K antagonist group. The risk of cardiovascular-related death (RR: 1.34; 95% CI: 0.69–2.60; P = 0.39; I 2 = 0%), clinically relevant nonmajor bleeding (RR: 0.90; 95% CI: 0.75–1.08; P = 0.26; I 2 = 28%), and hemorrhagic stroke (RR: 0.36; 95% CI: 0.06–2.24; P = 0.28; I 2 = 10%) showed no significant differences. In conclusion, the risks of all-cause stroke, ischemic stroke, all-cause mortality, major bleeding, gastrointestinal bleeding, and intracranial hemorrhage in patients with atrial fibrillation undergoing chronic hemodialysis were lower in the DOAC group.