Apixaban May Cut Stroke Risk but Raise Bleeding in Dialysis Patients

Observational data suggest apixaban leads to fewer thromboembolic events but higher bleeding risk in dialysis patients with atrial fibrillation.

Apr. 10, 2026 at 11:07am

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A highly detailed, translucent X-ray photograph revealing the intricate structures of the human heart and blood vessels, conveying the complex medical considerations for dialysis patients with atrial fibrillation.An X-ray view into the delicate balance of cardiovascular health and kidney function, highlighting the challenges of anticoagulation management for dialysis patients with atrial fibrillation.Houston Today

A new study found that initiating the oral anticoagulant apixaban in patients undergoing kidney dialysis who also had newly diagnosed atrial fibrillation (AF) was associated with fewer strokes and deaths but higher rates of bleeding events. The researchers used propensity score matching to balance baseline characteristics between patients who received apixaban and those who did not.

Why it matters

These findings add to the sparse observational evidence guiding apixaban use in patients undergoing kidney dialysis, as major clinical trials of apixaban did not include patients with end-stage renal disease. The study may help guide difficult conversations with patients about whether to proceed with oral anticoagulation, as clinicians often hesitate to prescribe anticoagulants due to bleeding concerns in this population.

The details

In intention-to-treat analyses, apixaban use was associated with a 25% lower rate of ischemic stroke and a 24% lower rate of a composite outcome of thromboembolic events and cardiovascular deaths. Conversely, patients who received apixaban had a 55% higher rate of hemorrhagic stroke and a 29% higher rate of clinically important bleeding. The hazard ratio for all-cause mortality was 0.61 (95% CI, 0.56-0.67). Treatment discontinuation was common, with 33% of patients not refilling their initial 30-day prescription and a median duration of apixaban treatment of 59 days.

  • The study used data from the US Renal Data System, including Medicare Part D claims on filled prescriptions, to identify patients with a first AF diagnosis between January 1, 2014, and December 31, 2019.

The players

Wolfgang C. Winkelmayer

MD, ScD, of Baylor College of Medicine in Houston, and the lead researcher of the study.

Paul M. Palevsky

An expert who was not involved in the study, and emphasized the importance of ensuring that patients undergoing dialysis who have newly diagnosed AF understand the risk-benefit profile.

An S. De Vriese

MD, PhD, of Ghent University in Belgium, who wrote an accompanying editorial calling for coordinated international efforts to conduct adequately powered trials in this complex population.

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What they’re saying

“Physicians can have meaningful discussions with their patients and consider whether the patient is more scared of a stroke or of a bleeding event and incorporate this into their decision-making.”

— Wolfgang C. Winkelmayer, Section Chief of Nephrology, Baylor College of Medicine

“The big takeaway from this is we need to talk to our patients about the risk of stroke, evaluate them on an individual basis for their various risks of complication, and have a very frank discussion about whether they want to be on anticoagulation.”

— Paul M. Palevsky

“Whether we opt for (kidney failure requiring hemodialysis) tailored risk stratification, DOAC dose reduction, or a new class of anticoagulants, we cannot resign ourselves to seeing our (kidney failure requiring hemodialysis) patients caught between the 'rock' of thrombosis and the 'hard place' of bleeding.”

— An S. De Vriese, MD, PhD, Ghent University

What’s next

A planned randomized controlled trial in Canada may provide more definitive evidence on the role of apixaban in patients undergoing dialysis. The trial, funded by the Canadian Institutes of Health Research, will compare apixaban with no anticoagulation and is expected to begin later this year.

The takeaway

This study highlights the complex risk-benefit profile of using apixaban in dialysis patients with atrial fibrillation, with potential reductions in stroke risk but increased bleeding events. It underscores the need for individualized decision-making and further clinical trials to guide anticoagulation management in this high-risk population.