Direct Oral Anticoagulants in Antiphospholipid Syndrome with End-Stage Renal Disease: Evidence-Based Clinical Review

Dr Abdul Mannan FRCPath FCPS

Blood🩸Doctor

[email protected]

Case credits to Dr Zunaira Amir, Indus Hospital, Karachi, Pakistan

Clinical Case Scenario

16-year-old patient with:

Congenital TTP (diagnosed age 5, on weekly plasma infusion)
End-stage kidney disease (peritoneal dialysis)
Antiphospholipid syndrome: isolated lupus anticoagulant positive (twice, 12 weeks apart, off anticoagulation)
Central retinal vein occlusion (CRVO) bilateral — arterial thrombotic manifestation
Deaf with speech disability

Clinical Question

<aside> ❓

Can apixaban be safely used for long-term anticoagulation in a patient with antiphospholipid syndrome (APS), arterial thrombosis, and end-stage renal disease on dialysis, when warfarin monitoring is challenging?

</aside>

Background

Antiphospholipid syndrome is a systemic autoimmune thrombophilia requiring long-term anticoagulation following thrombotic events. Vitamin K antagonists (VKAs) remain the gold standard, but direct oral anticoagulants (DOACs) offer theoretical advantages in patient compliance and monitoring.[1] However, recent randomised trials have raised concerns about DOAC efficacy in APS, particularly in high-risk phenotypes.[2,3]

This review synthesises evidence from randomised controlled trials, systematic reviews, and observational studies (2020–2025) to address anticoagulation options in complex APS with renal impairment.

Clinical Question

Background

Evidence Summary