Abstract

Background: Direct oral anticoagulants (DOACs) are widely used for stroke prevention in non-valvular atrial fibrillation, yet evidence regarding their safety profile in advanced chronic kidney disease (CKD stage 4-5) remains scarce due to trial exclusion criteria.

Methods: A retrospective cohort study utilizing nationwide registry data of patients aged ≥ 65 years with non-valvular AF and eGFR < 30 mL/min/1.73m2 initiated on oral anticoagulation between 2020 and 2025.

Results: Among 14,210 patients identified, apixaban was associated with significantly lower incidence of major bleeding compared to warfarin (HR 0.68, 95% CI: 0.58-0.80) while maintaining equivalent protection against ischemic stroke (HR 0.92, 95% CI: 0.77-1.10).

Conclusions: Appropriate dose-adjusted apixaban represents a favorable therapeutic alternative to warfarin in elderly patients with advanced CKD.