Oral anticoagulants and the risk of acute kidney injury: a retrospective real-world cohort study using overlap propensity score weighting
Abstract
BackgroundAnticoagulant-related nephropathy, initially described in association with warfarin, has increasingly been reported with direct oral anticoagulants (DOACs). However, the comparative risk of acute kidney injury (AKI) within 30 days of treatment initiation between warfarin and DOACs across a broad spectrum of clinical indications remains unclear.MethodsThis retrospective cohort study included patients newly initiated on DOACs or warfarin between January 2014 and May 2025 at the Third Xiangya Hospital of Central South University. Overlap propensity score weighting, with weights derived from a generalized boosted model incorporating 81 baseline covariates, balanced the treatment groups. Weighted logistic regression compared the risk of AKI within 30 days of OAC initiation, defined by KDIGO criteria. Sensitivity analyses included inverse probability of treatment weighting (IPTW) and logistic regression-derived overlap weighting, each with or without doubly robust covariate adjustment.ResultsAmong 6 876 patients (5 048 DOAC users; 1 828 warfarin users), DOAC initiation was associated with a higher risk of AKI than warfarin after overlap weighting (OR: 1.346, 95% CI: 1.057–1.715; p = 0.016), and with severe AKI (stage 2–3; OR: 1.694, 95% CI: 1.013–2.832; p = 0.044), whereas stage 1 AKI did not differ significantly. The association persisted after additional covariate adjustment (OR: 1.363, 95% CI: 1.068–1.740; p = 0.013) and across alternative propensity score models, although the unadjusted IPTW model did not. By indication, the association was significant for stroke prevention in atrial fibrillation (AF) (OR: 1.566, 95% CI: 1.034–2.369; p = 0.034) but not for venous thromboembolism (VTE) treatment or prophylaxis. Among individual DOACs, rivaroxaban was associated with an elevated risk (OR: 1.392, 95% CI: 1.075–1.804; p = 0.012), whereas edoxaban, dabigatran, and apixaban were not. Lower-dose rivaroxaban initiation was associated with an increased risk (OR: 2.792, 95% CI: 1.524–5.114; p = 0.001), whereas higher-dose and off-label use were not. In prespecified subgroup analyses, ORs were above 1 in most strata, but most comparisons were not significant, and no significant interactions were detected.ConclusionThese findings suggest that DOACs, particularly rivaroxaban, may be associated with a higher short-term risk of AKI than warfarin. Given the expanding use of DOACs, medication-specific renal effects warrant further investigation, and close monitoring of renal function may be advisable in high-risk patients after anticoagulation initiation.
Related
- Thirty-day clinical outcomes, early recovery, and healthcare resource use after planned ambulatory vs. conventional inpatient laparoscopic cholecystectomy: a propensity-score overlap-weighted retrospective cohort study
- Adjuvant Docetaxel–Cyclophosphamide Versus Anthracycline–Taxane Chemotherapy in Stage I–III HR-Positive/HER2-Negative Breast Cancer: A Real-World Propensity Score Overlap-Weighted Cohort Study
- Acyclovir and ganciclovir exposure and short-term outcomes in hospitalized children with EBV-associated mononucleosis-like illness: a retrospective cohort study using inverse probability of treatment weighting
- PO108 | DIRECT ORAL ANTICOAGULANTS IN PATIENTS WITH VENOUS THROMBOEMBOLISM RECEIVING LONG-TERM IMMUNOSUPPRESSIVE THERAPY AFTER LIVER AND KIDNEY TRANSPLANTATION: A SINGLE-CENTER EXPERIENCE
- Echinococcus granulosus Genotype and Surgical Outcomes After Cystic Echinococcosis Surgery: A Propensity-Score-Adjusted Retrospective Pilot Cohort Study
BibTeX
@article{li2026oral,
title = {{Oral anticoagulants and the risk of acute kidney injury: a retrospective real-world cohort study using overlap propensity score weighting}},
author = {Ping Li and Fang-Yuan Tian and Hao-Bo Liu and Man Rao and Wen-Jun Yin and Xiao-Cong Zuo and Ling-Yun Zhou},
journal = {Frontiers in Pharmacology},
year = {2026},
month = nov,
doi = {10.3389/fphar.2026.1935787},
url = {https://www.frontiersin.org/articles/10.3389/fphar.2026.1935787},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Oral anticoagulants and the risk of acute kidney injury: a retrospective real-world cohort study using overlap propensity score weighting
AU - Ping Li
AU - Fang-Yuan Tian
AU - Hao-Bo Liu
AU - Man Rao
AU - Wen-Jun Yin
AU - Xiao-Cong Zuo
AU - Ling-Yun Zhou
PY - 2026
DA - 2026/11/04
JO - Frontiers in Pharmacology
DO - 10.3389/fphar.2026.1935787
UR - https://www.frontiersin.org/articles/10.3389/fphar.2026.1935787
AB - BackgroundAnticoagulant-related nephropathy, initially described in association with warfarin, has increasingly been reported with direct oral anticoagulants (DOACs). However, the comparative risk of acute kidney injury (AKI) within 30 days of treatment initiation between warfarin and DOACs across a broad spectrum of clinical indications remains unclear.MethodsThis retrospective cohort study included patients newly initiated on DOACs or warfarin between January 2014 and May 2025 at the Third Xiangya Hospital of Central South University. Overlap propensity score weighting, with weights derived from a generalized boosted model incorporating 81 baseline covariates, balanced the treatment groups. Weighted logistic regression compared the risk of AKI within 30 days of OAC initiation, defined by KDIGO criteria. Sensitivity analyses included inverse probability of treatment weighting (IPTW) and logistic regression-derived overlap weighting, each with or without doubly robust covariate adjustment.ResultsAmong 6 876 patients (5 048 DOAC users; 1 828 warfarin users), DOAC initiation was associated with a higher risk of AKI than warfarin after overlap weighting (OR: 1.346, 95% CI: 1.057–1.715; p = 0.016), and with severe AKI (stage 2–3; OR: 1.694, 95% CI: 1.013–2.832; p = 0.044), whereas stage 1 AKI did not differ significantly. The association persisted after additional covariate adjustment (OR: 1.363, 95% CI: 1.068–1.740; p = 0.013) and across alternative propensity score models, although the unadjusted IPTW model did not. By indication, the association was significant for stroke prevention in atrial fibrillation (AF) (OR: 1.566, 95% CI: 1.034–2.369; p = 0.034) but not for venous thromboembolism (VTE) treatment or prophylaxis. Among individual DOACs, rivaroxaban was associated with an elevated risk (OR: 1.392, 95% CI: 1.075–1.804; p = 0.012), whereas edoxaban, dabigatran, and apixaban were not. Lower-dose rivaroxaban initiation was associated with an increased risk (OR: 2.792, 95% CI: 1.524–5.114; p = 0.001), whereas higher-dose and off-label use were not. In prespecified subgroup analyses, ORs were above 1 in most strata, but most comparisons were not significant, and no significant interactions were detected.ConclusionThese findings suggest that DOACs, particularly rivaroxaban, may be associated with a higher short-term risk of AKI than warfarin. Given the expanding use of DOACs, medication-specific renal effects warrant further investigation, and close monitoring of renal function may be advisable in high-risk patients after anticoagulation initiation.
SN - 1663-9812
ER -