*Purpose: Direct oral anticoagulants (DOACs) are increasingly used in renal transplant recipients (RTR). We aim to identify bleeding events and all-cause mortality between DOACs and warfarin post-transplant.

*Methods: We conducted a retrospective study of kidney transplant patients at the Mayo Clinic sites (2011-present) that were anticoagulated for greater than 3 months excluding the 1^st month post-transplant. Those with mechanical valves, antiphospholipid antibody syndrome, and ventricular thrombus were excluded. The main safety outcomes assessed were bleeding and all-cause mortality and compared for DOACs versus warfarin. Concomitant antiplatelet and interacting drugs were noted. DOAC dose adjustment and correctness was assessed according to common US prescribing practices/guidelines/FDA labeling.

*Results: The median follow-up was 796 days (371, 1261). There were no significant differences in baseline (time of transplant) age, gender, BMI, diabetes, cardiovascular disease (CVE), atrial fibrillation (afib), venous thromboembolism (VTE), GI bleeding, intra-cranial hemorrhage (ICH), ischemic stroke, between those on DOACs (n=208; apixaban 91.3%, rivaroxaban 8.7%) vs. warfarin (n=320). There was no difference in post-transplant use of aspirin, other antiplatelet, fluconazole, voriconazole, posaconazole, amiodarone, tacrolimus, cyclosporine, or other immunosuppressant. Past or current smoking and use of itraconazole was higher in the DOAC group. The warfarin group had higher incident major bleeding (8.4 vs. 5.3%, p=0.17), GI bleeding (4.4% vs. 1.9%, p=0.13), ICH (1.9% vs. 1.4%, p=0.71), and higher mortality (22.2% vs. 10.1%, p=0.0003) compared to DOACs. These differences were explained by longer follow-up time for warfarin group compared to DOACs. On multivariate analysis, only older age, diabetes and history of smoking were significant predictors of mortality. Post-transplant VTE, afib and stroke were not significantly different. 68% of patients on DOACs were dose reduced, where 50% of those dose reductions were warranted. 7% of patients that were not dose reduced should have been.

*Conclusions: DOACs did not have inferior bleeding or mortality outcomes compared to warfarin in RTRs; however, further studies with longer follow-up are needed to define any outcome benefit. There was greater use of warfarin compared to DOACs and a high rate of improper DOAC dose reduction.

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