Abstract
Background: Older adults with atrial fibrillation (AF) and chronic kidney disease (CKD) stage 4–5 have simultaneously high risks of ischemic stroke and anticoagulant-related bleeding. Evidence guiding drug selection is limited because pivotal direct oral anticoagulant (DOAC) trials largely excluded patients with severe renal impairment.
Objective: To review contemporary comparative evidence for apixaban, rivaroxaban, and warfarin in older adults with advanced CKD, with emphasis on major bleeding, thromboembolism, renal function, dose selection, and the distinction between non-dialysis CKD and kidney failure requiring dialysis. Summary: Observational data consistently suggest that apixaban is associated with less major bleeding than warfarin or rivaroxaban in non-dialysis CKD stage 4–5, while stroke rates appear broadly similar but are less precisely estimated. A 2024 nationwide US cohort found major bleeding to be higher with warfarin and rivaroxaban than with apixaban. A separate cohort of patients with severe CKD, mean age 78.5 years, similarly found lower major bleeding with apixaban than with warfarin or rivaroxaban. Recent 2026 analyses continue to support a favorable apixaban safety signal, but certainty remains limited by confounding and sparse randomized evidence. In dialysis, small randomized trials have not established clear superiority of apixaban or vitamin K antagonists.
Conclusion: In older adults with AF and non-dialysis advanced CKD who require anticoagulation, apixaban currently has the most consistent observational safety signal. Warfarin remains appropriate in selected patients, particularly when DOACs are unsuitable. Anticoagulation in kidney failure requiring dialysis should remain individualized because the net clinical benefit is uncertain.
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Ethics & Declarations
Author Contributions
All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by all authors. All authors read and approved the final manuscript.
Ethics Approval and Consent to Participate
Not applicable. This study did not involve human participants, animal experimentation, or confidential patient clinical data.
Consent for Publication
Not applicable, or informed consent for publication was obtained from all individual participants where relevant.
Competing Interests
The authors declare that they have no competing financial or non-financial interests.
Funding
The authors declare that no funds, grants, or other financial support were received during the preparation of this manuscript.
Data Availability Statement
Data sharing is not applicable to this article as no new datasets were generated or analyzed during the current study.
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© 2026 MOHAMED ABDELLATIF et al. International Journal of Clinical Pharmacy and Medicine.