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Original Article
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Korean J Intern Med. 2026;41(1):107-117. Published online January 1, 2026.
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
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Yujin Yang1, Sun Hwa Lee2, Wonmook Hwang3, Ji Hoon Jung4, Jae-Hyeong Park1
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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
