A Review of Direct Oral Anticoagulants in Patients With Stage 5 or End-Stage Kidney Disease

Ann Pharmacother. 2022 Jun;56(6):691-703. doi: 10.1177/10600280211040093. Epub 2021 Aug 29.


Objective: To evaluate the role of oral anticoagulation in patients with stage 5 chronic kidney disease (CKD-5) or end-stage kidney disease (ESKD).

Data sources: A literature search of PubMed (January 2000 to July 1, 2021), the Cochrane Library, and Google Scholar databases (through April 1, 2021) was performed with keywords DOAC (direct-acting oral anticoagulant) OR NOAC or dabigatran OR rivaroxaban OR apixaban OR edoxaban AND end-stage kidney disease combined with atrial fibrillation (AF) or venous thromboembolism (VTE) OR pulmonary embolism OR deep-vein thrombosis.

Study selection and data extraction: Case-control, cohort, and randomized controlled trials comparing DOACs to an active control for AF or VTE in patients with CKD-5 or ESKD and reporting outcomes of stroke, recurrent thromboembolism, or major bleeding were included.

Data synthesis: Nine studies were included. Efficacy data supporting routine use of warfarin or DOACs in CKD-5 or ESKD are limited. Rivaroxaban and apixaban may provide enhanced safety compared to warfarin in patients with AF. Data for VTE are limited to 1 retrospective study.

Relevance to patient care and clinical practice: Because of the paucity of rigorous, prospective studies in CKD-5 or ESKD, OACs should not be broadly used in this population. It is clear that data regarding efficacy of DOACs cannot be reliably and safely extrapolated from the non-ESKD population. Therefore, use of OACs in this population should be individualized.

Conclusions: If OACs for stroke prevention with AF are deemed necessary, apixaban or rivaroxaban can be considered. DOACs cannot currently be recommended over warfarin in patients with CKD-5 or ESKD and VTE.

Keywords: DOAC; anticoagulation; apixaban; atrial fibrillation; bleeding; dialysis; stroke; thrombosis; warfarin.

Publication types

  • Review

MeSH terms

  • Administration, Oral
  • Anticoagulants* / administration & dosage
  • Atrial Fibrillation* / complications
  • Atrial Fibrillation* / drug therapy
  • Humans
  • Kidney Failure, Chronic* / complications
  • Kidney Failure, Chronic* / drug therapy
  • Renal Insufficiency, Chronic* / complications
  • Renal Insufficiency, Chronic* / drug therapy
  • Stroke* / etiology
  • Stroke* / prevention & control
  • Venous Thromboembolism* / complications
  • Venous Thromboembolism* / drug therapy
  • Venous Thromboembolism* / prevention & control


  • Anticoagulants