The risk of acute kidney injury in Asians treated with apixaban, rivaroxaban, dabigatran, or warfarin for non-valvular atrial fibrillation: A nationwide cohort study in Taiwan

Background: Whether or not non-vitamin K antagonist oral anticoagulants (NOACs) are associated with a lower risk of acute kidney injury (AKI) in patients with non-valvular atrial fibrillation (NVAF) remains unknown in real world practice. Methods: In this nationwide retrospective cohort study, 1507, 3200, 5765 and 4227 NVAF patients with chronic kidney disease (CKD) and 4368, 16,945, 22,301, and 16,908 NVAF patients without CKD taking apixaban, dabigatran, rivaroxaban, and warfarin, respectively, from June 1, 2012 to December 31, 2016 were enrolled from the Taiwan National Health Insurance Program. Propensity-score weighted method was used to balance covariates across study groups. Patients were followed until occurrence of AKI or end date of study. Results: Three NOACs were all associated with a significantly lower risk of AKI compared with warfarin for both CKD-free (hazard ratio, [95% confidential interval]; 0.65, [0.60–0.72] for apixaban; 0.68, [0.64–0.74] for dabigatran; 0.73, [0.68–0.79] for rivaroxaban) and CKD cohorts (0.50, [0.45–0.56] for apixaban; 0.54, [0.49–0.59] for dabigatran; 0.53, [0.49–0.58] for rivaroxaban). The annual incidence of AKI for all NOACs and warfarin increased gradually as the increment of CHA₂DS₂-VASc for both CKD-free and CKD cohorts after propensity score weighting. The reduced risk of AKI for three NOACs persisted in most subgroups in either CKD-free or CKD cohort. Multivariate analysis indicated that all three NOACs were all associated with lower risk of AKI than warfarin in either CKD-free or CKD cohort. Conclusions: All three NOACs are associated with a lower risk of AKI than warfarin among Asians with NVAF in real-world practice.