Safety and efficacy of direct oral anticoagulants in kidney transplant recipients: A systematic review and meta-analysis.
Roca Mora, M. M., et al.Transplantation Reviews 2025; 39(1): 100899.
Aims
This study aimed to investigate the effect of direct-acting oral anticoagulants (DOACs) in comparison to vitamin K antagonists (VKAs) in kidney transplant patients.
Interventions
A literature search was conducted in PubMed, Cochrane Central, and Embase databases. Two reviewers independently selected studies for inclusion and three independent reviewers extracted the data. The Risk of Bias in Non-Randomized Studies of Intervention (ROBINS-I) tool was used to assess the quality of the included studies.
Participants
5 studies were included in the review.
Outcomes
Major bleeding, mortality and graft failure were the primary outcomes. Venous thromboembolism and changes in estimated glomerular filtration rate were included as the secondary outcomes.
Follow-up
N/A
CET Conclusions
Direct-acting oral anticoagulants (DOAC) have increasingly been prescribed in the general population for the prevention and treatment of thrombo-embolic disease as they have been shown to have similar efficacy and safety compared to warfarin therapy, without requiring regular monitoring. DOAC use in kidney transplant recipients (KTR), however, has not been as frequent because of concerns of unpredictable efficacy due to variable renal clearance and drug interactions with immunosuppressant agents. This systematic review synthesized the available data comparing the use of DOACs and warfarin therapy in KTRs. The primary outcomes were major bleeding rate, mortality and graft failure. Five studies were included comprising 959 patients. None of the studies were randomised and all were judged to have a moderate risk of bias. Mortality and rates of major bleeding were significantly lower in the DOAC group, but there was no significant decrease in rates of graft failure between the two groups. The findings of the included studies (and by extension those of this meta-analysis), have a major selection bias – warfarin therapy is preferred in patients with more severe illness (e.g. atrial fibrillation associated with valvular heart disease). This renders the authors conclusion that DOACs are safer in KTRs ungeneralisable.
Trial registration
PROSPERO - CRD42024498423