Direct oral anticoagulants versus vitamin K antagonists for atrial fibrillation patients on dialysis: A systematic review and meta-analysis of randomized controlled trials and real-world evidence.

Atrial fibrillation (AF) is the most common arrhythmia in end-stage renal disease (ESRD) patients on dialysis. These patients face high risks of both thromboembolism and bleeding. Pivotal randomized controlled trials (RCTs) of direct oral anticoagulants (DOACs) excluded these patients, leaving the optimal anticoagulant choice uncertain. We conducted a systematic review and meta-analysis investigating the efficacy and safety of DOACs versus VKAs in AF patients undergoing dialysis. We searched PubMed, Scopus, Web of Science, and Cochrane Library for RCTs and observational studies. Primary outcomes were ischemic stroke, major bleeding, and all-cause mortality. Secondary outcomes included ischemic stroke or systemic embolism, other bleeding events, hemorrhagic stroke, myocardial infarction, and cardiovascular mortality. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated. Four RCTs and nine observational studies were included in this study, encompassing 31,238 patients. DOACs were associated with significantly lower risk of major bleeding (RR: 0.68, 95% CI [0.49-0.95], I2 = 89.0%), gastrointestinal bleeding (RR: 0.74, 95% CI [0.61-0.90], I2 = 37.1%), and hemorrhagic stroke (RR: 0.23, 95% CI [0.07-0.78], I2 = 1.5%) compared to VKAs. Both groups showed similar risk of ischemic stroke (RR: 0.59, 95% CI [0.32-1.09], I2 = 40.8%), all-cause mortality (RR: 0.85, 95% CI [0.68-1.07], I2 = 73.2%). Other secondary outcomes also showed no significant differences. In AF patients with ESRD receiving dialysis, DOACs provide similar efficacy and lower bleeding risk compared to VKAs. Among DOACs, apixaban appears to offer the greatest net clinical benefit in this population.