*Purpose: Safety and efficacy of direct-acting oral anticoagulants (DOACs) have not been well studied in solid organ transplant. The purpose of our study was to compare the safety and efficacy of DOACs to warfarin in kidney transplant recipients.

*Methods: In this single-center retrospective study, we evaluated 197 adult kidney transplant recipients who initiated DOAC or warfarin between January 2011 to June 2018. The primary outcome was major bleeding defined as Hgb decrease ≥ 2 g/dl, blood transfusion ≥ 2 units, or symptomatic bleeding in a critical area or organ.

*Results: Patients were initiated on oral anticoagulation at a median of 6.5 years post-transplant and followed for a median of 12.3 (IQR 5.2-27.5) months. Baseline characteristics were well matched, except for calendar year of anticoagulation initiation, Hgb, and concomitant antiplatelet use at time of anticoagulation initiation (Table 1). Rates of major bleeding were 11.4% per year with warfarin vs. 7.2% per year with DOACs (Figure 1, Mantel-Cox p=0.15). No difference was found in composite bleeding, clinically relevant nonmajor bleeding, or thromboembolic events (Table 2). There was a lower incidence of major bleeding with apixaban compared to all other anticoagulants (6.7% vs. 19.0%, P=0.027). After controlling for potential confounders, DOAC use was not associated with an increased risk of major bleeding (HR 0.93, 95% CI 0.27-1.95).

*Conclusions: These findings indicate that DOACs are safe and effective alternatives to warfarin for anticoagulation in kidney transplant recipients.

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