Among patients with AF and advanced CKD not receiving dialysis, anticoagulation was associated with reduced risk of ischemic stroke but increased risk of bleeding compared with nonuse, suggesting that the trade-off between ischemic stroke reduction and bleeding risk was more favorable for apixaban than for warfarin.
Apixaban was associated with increased major bleeding risk compared with no oral anticoagulation in patients with AF and advanced CKD.
Apixaban was associated with a significantly lower rate of ischemic stroke compared with no oral anticoagulation.
Apixaban showed no statistically significant association with the composite outcome of major bleeding and ischemic stroke compared with no oral anticoagulation.
Warfarin was associated with substantially higher major bleeding risk and no significant ischemic stroke reduction compared with no oral anticoagulation.
Apixaban was associated with lower risk of both major bleeding and ischemic stroke compared with warfarin.
The study used a target trial emulation framework with large claims databases spanning up to a decade of follow-up.
This research studied whether blood thinners (anticoagulants) help or harm patients who have both atrial fibrillation (an irregular heart rhythm) and advanced kidney disease (stages 4 or 5) but are not yet on dialysis. Using over a decade of insurance claims data from more than 42,000 patients, researchers compared two types of blood thinners—apixaban (a newer drug) and warfarin (an older drug)—against no blood thinner use. They found that apixaban significantly reduced strokes by about 54% compared to no treatment, but also increased the risk of major bleeding by 32%. When these two effects were combined, the overall benefit and harm roughly balanced out for apixaban. Warfarin, by contrast, dramatically increased bleeding risk (about 2.4 times higher) without significantly reducing strokes, resulting in a worse overall outcome compared to taking no blood thinner at all. When apixaban and warfarin were compared directly against each other, apixaban was clearly better—cutting both bleeding risk and stroke risk approximately in half. This suggests that if a blood thinner is to be used in this patient population, apixaban is the preferable choice. The findings are particularly important because patients with advanced kidney disease are at high risk for both strokes and bleeding, and it has long been unclear whether the benefits of anticoagulation outweigh the risks in this group. This research suggests that the decision to use apixaban in patients with atrial fibrillation and advanced kidney disease involves a meaningful trade-off: fewer strokes but more bleeding events, with the overall net effect being roughly neutral compared to no treatment. Warfarin appears to offer little benefit and significant harm in this population. These findings may help inform clinical decision-making for a patient group that has historically been underrepresented in clinical trials, though individual patient circumstances and preferences remain important considerations.
Chen Q, Singer D, Fu E, Yang C, Pritchard K, Desai R, et al.. (2026). Oral Anticoagulants in Patients With Atrial Fibrillation and Advanced CKD Not Requiring Dialysis.. JAMA network open. https://doi.org/10.1001/jamanetworkopen.2026.32225