Anticoagulant Medications for Patients With Atrial Fibrillation and Advanced Renal Disease: A Propensity-Matched Real-World Analysis of Apixaban vs Rivaroxaban

Background Advanced chronic kidney disease (CKD) complicates anticoagulant treatment because thromboembolic and bleeding risks compete. We compared treatment outcomes for apixaban and rivaroxaban in adults with atrial fibrillation (AF) and stage 4/5 CKD. Methods Deidentified TriNetX records for patients treated with apixaban (n=49,698) and rivaroxaban (n=2660) underwent 1:1 propensity score matching (demographics, medications, procedures, laboratory values); 2533 matched pairs were identified (absolute standardized mean difference <0.10, indicating adequate balance). The smaller rivaroxaban cohort constrained matching; findings apply only to the matched population. Outcomes were assessed at 1, 3, and 5 years. Myocardial infarction (MI) findings were exploratory. P values were not adjusted for multiplicity. Results Gastrointestinal bleeding was lower for apixaban vs rivaroxaban (5-year: 9.3% vs 10.9%; relative risk [RR], 0.86; 95% CI, 0.71-1.02; P=.09). Cerebrovascular events were significantly higher for apixaban vs rivaroxaban at 3 years only (9.8% vs 7.9%; RR, 1.24; 95% CI, 1.01-1.53; P=.04); this association may reflect chance. Cerebral infarction was significantly higher for apixaban vs rivaroxaban at 1 year (3.0% vs 1.8%; RR, 1.61; 95% CI, 1.09-2.37; P=.02) and attenuated at 3 and 5 years. Rates of MI were nominally higher in the apixaban group. Five-year mortality risk was significantly lower for apixaban vs rivaroxaban (33.3% vs 36.1%; RR, 0.92; 95% CI, 0.86-0.10; P=.04) but differences in time-to-event survival were not significant. Conclusion Apixaban did not have greater bleeding risk than rivaroxaban and may be associated with lower gastrointestinal bleeding, a finding that requires further study. Isolated cerebrovascular, MI, and mortality findings require cautious interpretation. A mortality advantage for either drug was not established.