Safety and efficacy of direct oral anticoagulants in kidney transplant recipients: A systematic review and meta-analysis

Introduction

Direct-acting oral anticoagulants (DOACs) have recently shown potential efficacy for many conditions without the need for regular monitoring. However, their use in kidney transplant recipients (KTRs) is controversial, with no clear consensus on how they compare to vitamin K antagonists (VKAs), which have traditionally been used as preferred anticoagulation therapy in these patients.

Methods

PubMed, Cochrane Central, and Embase databases were systematically searched up to December 2023 for studies comparing DOACs versus VKAs in KTRs. The main outcomes of interest included venous thromboembolism (VTE), major bleeding, graft failure, mortality, and changes in estimated glomerular filtration rate (eGFR). Statistical analyses were performed using RStudio 4.1.2 software. PROSPERO ID: CRD42024498423.

Results

Five studies with a total of 959 participants were included. Of these, 433 (45.15 %) participants were treated with DOACs. The mean age of participants was 60.05 years, and 65.9 % were male. The use of DOACs in KTRs was associated with a significant reduction in major bleeding (RR 0.56; 95 % CI 0.35 to 0.90; p = 0.02; I² = 0 %) and mortality (RR 0.49; 95 % CI 0.33 to 0.74; p = 0.0006; I² = 0 %). No significant differences were found between groups in VTE (RR 0.82; 95 % CI 0.47 to 1.43; p = 0.48; I² = 12 %), graft failure (RR 0.43; 95 % CI 0.14 to 1.27; p = 0.13; I² = 52 %), and eGFR (MD 3.72 mL/Kg/1.73 m2; 95 % CI -1.58 to 9.03; p = 0.17; I² = 0 %). Evidence quality for some outcomes remains low to moderate, limiting the confidence in these conclusions.

Conclusion

Our meta-analysis suggests that DOACs represent an effective anticoagulation strategy in KTR, with a significant reduction in major bleeding and mortality relative to VKA.