Compared with warfarin, apixaban may lower the risks of recurrent venous thromboembolism (VTE) and major bleeding in patients receiving dialysis, a new study finds.

Using 2013-2018 United States Renal Data System data, investigators studied 12,206 Medicare fee-for-service beneficiaries receiving dialysis who had a recent VTE and were new users of oral anticoagulants.

In intention-to-treat analyses, apixaban, a direct oral anticoagulant (DOAC), was significantly associated with a 42% reduced risk for recurrent VTE and a 22% reduced risk of major bleeding events compared with warfarin, James B. Wetmore, MD, of Hennepin Healthcare Research Institute, Minneapolis, Minnesota, and colleagues reported in the Clinical Journal of the American Society of Nephrology. Nearly three-quarters of the major bleeding events were gastrointestinal, and a minority were cerebral. These results stayed consistent in sensitivity analyses, such as in patients with and without atrial fibrillation, antiplatelet therapy, cancer, or recent surgery. There was no difference in mortality risk between apixaban and warfarin users.

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“A goal for the nephrology community should be to conduct a clinical trial in patients receiving maintenance dialysis, testing apixaban and other indicated DOACs against warfarin following a diagnosis of a venous thromboembolism,” Dr Wetmore’s team concluded.

In an accompanying editorial, Thomas Mavrakanas, MD, of Montreal General Hospital, Quebec, Canada, praised the study but emphasized that several outstanding questions remain before apixaban can be used in the dialysis population for VTE disease. First, how should patients with kidney failure be treated during the acute phase? He noted that patients with low kidney function might start with low molecular weight heparin before switching to apixaban. Second, what is the optimal maintenance dose for apixaban in kidney failure? Third, would drug monitoring help with dose adjustment? Fourth, how should clinicians manage patients with unprovoked VTE considered for long-term anticoagulation? Fifth, how should patients at high risk of recurrence be treated? Lastly, how high is the risk for bleeding with use of antiplatelet agents in patients receiving therapeutic anticoagulation?

“Until we can be better informed, treatment approaches should be individualized, and expert advice should be sought,” according to Dr Mavrakanas.

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Wetmore JB, Herzog CA, Yan H, et al. Apixaban versus warfarin for treatment of venous thromboembolism in patients receiving long-term dialysis. Clin J Am Soc Nephrol. Published online April 25, 2022. doi:10.2215/CJN.14021021

Mavrakanas TA. Treatment options for venous thromboembolism in patients receiving dialysis. Clin J Am Soc Nephrol. Published online April 25, 2022. doi:10.2215/CJN.03410322