Comparative efficacy and safety of warfarin and direct oral anticoagulants in patients with end-stage renal disease and atrial fibrillation

Yang, Yujin; Lee, Sun Hwa; Hwang, Wonmook; Jung, Ji Hoon; Park, Jae-Hyeong

doi:2026.41.1.107

Korean J Intern Med > Volume 41(1); 2026 > Article

ORIGINAL ARTICLE

Cardiology

Korean J Intern Med. 2026;41(1):107-117. doi: https://doi.org/10.3904/kjim.2025.052

Comparative efficacy and safety of warfarin and direct oral anticoagulants in patients with end-stage renal disease and atrial fibrillation

Yujin Yang¹, Sun Hwa Lee², Wonmook Hwang³, Ji Hoon Jung⁴, and Jae-Hyeong Park¹

¹Department of Cardiology in Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
²Division of Cardiology, Department of Internal Medicine, Jeonbuk National University Medical School and Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Korea
³Department of Cardiology in Internal Medicine, Chungnam National University Sejong Hospital, Sejong, Korea
⁴Division of Statistics, Office of Information Security, Korea Institute of Toxicology, Daejeon, Korea

Corresponding Author: Jae-Hyeong Park , Tel: +82-42-280-7187, Fax: +82-42-280-7187, Email: jaehpark@cnu.ac.kr

Received: February 13, 2025; Revised: April 8, 2025; Accepted: April 11, 2025.

Abstract

Background/Aims: Patients with atrial fibrillation (AF) and end-stage renal disease (ESRD) require careful anticoagulation because thrombotic and bleeding risks are both elevated. We evaluated the efficacy and safety of warfarin, direct oral anticoagulants (DOACs), and no anticoagulation in Korean patients with ESRD and AF.
Methods: In this multicenter retrospective study, we included 933 patients with ESRD and nonvalvular AF treated between 2010 and 2023. Patients were assigned to three groups by initial treatment: no anticoagulation (n = 604), warfarin (n = 197), or DOACs (n = 132). The primary efficacy outcome was ischemic stroke or systemic embolism (IS/SE); the primary safety outcome was major bleeding (MB). Secondary outcomes were intracranial hemorrhage (ICH), gastrointestinal bleeding (GIB), and all-cause mortality. Inverse probability of treatment weighting was used to adjust for confounding.
Results: Both warfarin (adjusted hazard ratio [aHR], 0.55) and DOACs (aHR, 0.36) significantly reduced the risk of IS/SE compared with no anticoagulation. However, warfarin increased MB risk compared with no anticoagulation (aHR, 2.69), including ICH and GIB. DOACs also increased MB risk versus no anticoagulation (aHR, 1.37), driven primarily by ICH. Compared with warfarin, DOACs showed a lower MB risk (aHR, 0.51). Both warfarin and DOACs reduced all-cause mortality relative to no anticoagulation (aHR, 0.53 and 0.57, respectively).
Conclusions: Among Korean patients with ESRD and AF, both warfarin and DOACs reduced IS/SE but increased MB. Given their lower MB risk than warfarin, DOACs may be preferable for anticoagulation in this high-risk population.

Keywords: Atrial fibrillation ; End-stage renal disease ; Anticoagulants ; Factor Xa inhibitors