Dilemmas in the Management of Atrial Fibrillation in Chronic Kidney Disease

Department of Cardiology and Angiology, Medizinische Klinik und Poliklinik C, University Hospital of Muenster, Muenster, Germany.
Journal of the American Society of Nephrology (Impact Factor: 9.34). 04/2009; 20(4):705-11. DOI: 10.1681/ASN.2007111207
Source: PubMed


Patients with chronic kidney disease (CKD) have an increased risk for cardiovascular morbidity and mortality. Little attention has been paid to the problem of atrial fibrillation, although this arrhythmia is very frequent with a prevalence of 13 to 27% in patients on long-term hemodialysis. Because of the large number of pathophysiologic mechanisms involved, these patients have a high risk for both thromboembolic events and hemorrhagic complications. Stroke is a frequent complication in CKD: The US Renal Data System reports an incidence of 15.1% in hemodialysis patients compared with 9.6% in patients with other stages of CKD and 2.6% in a control cohort without CKD. The 2-yr mortality rates after stroke in these subgroups were 74, 55, and 28%, respectively. Although oral coumadin is the treatment of choice for atrial fibrillation, its use in patients with CKD is reported only in limited studies, all in hemodialysis patients, and is associated with a markedly increased rate of bleeding compared with patients without CKD. With regard to the high risk for stroke and the conflicting data about oral anticoagulation, an individualized stratification algorithm is presented based on relevant studies.

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    • "Hart et al22 reported a higher rate of ischemic stroke in patients with moderate CKD and AF from the Stroke Prevention in Atrial Fibrillation trials and showed that treatment with warfarin reduced this risk. However, management of AF in patients with CKD is significantly more complex because of the higher bleeding risk related to anticoagulation,3,23 which also could contribute to the increased observed mortality rate. Nakagawa et al11 found that patients with CKD, AF, and higher thomboembolic risk scores are at extremely high risk, but any potential contribution of anticoagulation to the increased mortality hazard in this population cannot be determined from this study. "
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    ABSTRACT: Atrial fibrillation (AF) and chronic kidney disease (CKD) are prevalent in the elderly and are independently associated with increased risk of death. We evaluated risk of incident AF with advancing CKD and examined the mortality rate associated with CKD after incident AF in elderly patients. This retrospective cohort study used the Medicare 5% database. Point-prevalent Medicare enrollees on December 31, 2006, without preexistent AF or end-stage renal disease were followed up for incident AF through 2008. CKD and AF were identified from International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Associations between CKD stage and incident AF and subsequent risk of death were examined in a Cox proportional-hazards model. Unadjusted survival after incident AF was estimated by the Kaplan-Meier method. CKD was present in 55 962 patients (5.1% of the cohort). Of these, 4952 (8.8%) had CKD stages 1 and 2; 19 795 (35.3%), stages 3 to 5; and 31 215 (55.7%), unknown stage. The hazard ratio for incident AF in CKD stages 3 to 5 was 1.13 (95% confidence interval 1.09 to 1.18). Other stages were not independently associated with incident AF. Survival after incident AF decreased progressively as CKD stage increased (P<0.0001). The 1-year mortality rate for CKD stages 3 to 5 with incident AF was 35.6%. Adjusted hazard ratios for death after incident AF were 1.14 (95% confidence interval 1.00 to 1.30) for CKD stages 1 and 2, 1.27 (95% confidence interval 1.20 to 1.35) for CKD stages 3 to 5, and 1.29 (95% confidence interval 1.23 to 1.36) for unknown stage. Advanced CKD is associated with increased risk of incident AF. In Medicare patients with incident AF, mortality rates are higher for those with advanced CKD than for those without CKD. (J Am Heart Assoc. 2012;1:e002097 doi: 10.1161/JAHA.112.002097.).
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    ABSTRACT: Despite the importance of cardiovascular disease in dialysis patients, the frequency of atrial fibrillation in incident dialysis patients has not been determined. We analyzed the prevalence of atrial fibrillation in patients starting dialysis over a 4-year period, its occurrence over the course of dialysis, and its influence on ischemic stroke and mortality. Factors predisposing to atrial fibrillation were noted, as was the influence of arrhythmia on mortality and presentation of ischemic stroke. Of the 256 patients studied, 31 had atrial fibrillation at the start of dialysis. Increased age, larger left atrium, and female gender were independently related to the presence of atrial fibrillation at dialysis inception. Of the 225 patients who were in sinus rhythm at the start of dialysis, 28 developed atrial fibrillation during a mean follow-up time of 2 years. The presence of valvular calcifications, bundle branch block, previous ischemic stroke, lower ejection fraction, higher pulse pressure, and lower hemoglobin concentration were predictors of the clinical evolution of atrial fibrillation. Overall, atrial fibrillation increased mortality risk 1.72-fold and ischemic stroke risk 9.8-fold. Therefore, it appears that atrial fibrillation is quite prevalent and its presence is associated with significant risk.
    Kidney International 07/2009; 76(3):324-30. DOI:10.1038/ki.2009.185 · 8.56 Impact Factor
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