| Background:Chronic kidney disease (CKD) increases the risk of stroke in nonvalvular atrial fibrillation (NVAF) patients. Novel oral anticoagulants (NOACs)(dabigatran, apixaban and rivaroxaban) have been approved for stroke prevention in NVAF patients combined with CKD. However, impaired kidney function may alter the antithrombotic effect of NOACs and increase the bleeding risk. A systemic review and indirect Meta-analysis was performed to compare the efficacy and safety of these three NOACs in NVAF patients with CKD based on the data from warfarin-controlled randomized trials.Methods:Databases were searched for warfarin-controlled randomized trials for NVAF. The primary efficacy outcomes were stroke or systemic embolism. The primary safety outcomes were major bleeding, intracranial bleeding and all cause mortality. CKD was defined as creatinine clearance (CrCl)≤50mL/min using the Cockroft-Gault formula. The R software was used for direct and indirect comparisons. Results:Four trials (two trials evaluated rivaroxaban, one dabigatran and one apixaban) were included in the analysis, enrolling9776patients. Pair-wise Meta-analysis showed that NOACs significantly decreased the risk of stroke or systemic embolism compared to warfarin, while there were no significant differences in the rates of major bleeding, intracranial bleeding and all cause mortality in NVAF patients with CKD. Indirect Meta-analysis did not reveal a significant difference among rivaroxaban, dabigatran, and apixaban in preventing stroke or systemic embolism, while apixaban significantly reduced the risk of major bleeding in comparison to dabigatran or rivaroxaban.Conclusion:Compared with dose-adjusted warfarin, NOACs are non-inferior and relatively safe in NVAF patients with CKD. Apixaban significantly decreases the risk of major bleeding compared to dabigatran and rivaroxaban. Head-to-head clinical trials are required to confirm these conclusions. |
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