Dilemmas in the Management of Atrial Fibrillation in Chronic Kidney Disease
ABSTRACT 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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ABSTRACT: Dabigatran etexilate represents a possible improved alternative to warfarin for anticoagulation in hemodialysis patients with atrial fibrillation (AF). The objective was to determine dabigatran plasma concentrations and anticoagulant effects following administration of a single 110 mg oral dose of dabigatran etexilate to 10 adult patients immediately prior to starting hemodialysis. Mass spectrometry and the Hemoclot® assay were used, respectively, to determine free (unconjugated) dabigatran concentrations and thrombin time (TT) in plasma samples collected intermittently over 48 hours. The median time (tmax) to reach the maximum plasma free dabigatran concentration (Cmax) was 2 h (range 1–3 h). The mean free dabigatran Cmax was 95.5 ± 33.4 ng mL-1. The mean elimination half-lives on and off hemodialysis were, respectively 2.6 ± 1.3 h and 30.2 ± 7.8 h. Hemodialysis effectively removed dabigatran with an extraction ratio of 0.63 ± 0.07. The maximal TT ratio was 2.1 and the TT ratio demonstrated a strong linear dependence on free dabigatran concentration (r2 = 0.741). A 110 mg oral dabigatran dose prior to hemodialysis was rapidly absorbed and achieved therapeutic concentrations. Hemodialysis effectively removed dabigatran from the plasma and may be an effective means of accelerating the elimination of dabigatran in circumstances of excessive anticoagulation.The Journal of Clinical Pharmacology 05/2014; DOI:10.1002/jcph.335 · 2.47 Impact Factor
Journal of Cardiology 10/2014; 57. DOI:10.1016/j.jjcc.2014.10.001 · 2.57 Impact Factor
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ABSTRACT: Background Renal impairment is associated with poor prognosis in the setting of atrial fibrillation (AF). While AF catheter ablation is an effective treatment modality for AF burden reduction and improvement of symptoms, changes in renal function after catheter ablation and their association with rhythm outcome have not been studied in a large contemporary AF ablation cohort. Objective To determine the association between CHADS(2) and CHA(2)DS(2)-VASc scores and arrhythmia recurrences with changes in renal function following AF catheter ablation. Methods Estimated glomerular filtration rate (eGFR) was estimated using the Chronic Kidney Disease Epidemiology Collaboration equation at baseline and during follow-up in 783 patients undergoing de novo AF catheter ablation. Complete rhythm follow-up was achieved in 626 patients (80%) using serial 7-day Holter ECG. Results The study population (n=783, 61+/-10 years, 64% men, 57% paroxysmal AF) was followed up at median 20 (IQR 12-27) months. Baseline eGFR correlated with CHADS(2) (beta=-0.258, p< 0.001) and CHA(2)DS(2)-VASc scores (beta=-0.434, p< 0.001). On multivariable analyses, eGFR changes were associated with AF recurrences (B=-0.136, p= 0.014), CHADS(2) (B=-0.062, p= 0.035) and CHA(2)DS(2)-VASc scores (B=-0.057, p= 0.003). Conclusions In patients after AF catheter ablation, eGFR changes during mid-term follow-up are associated with AF recurrences, CHADS(2) and CHA(2)DS(2)-VASc scores.Heart (British Cardiac Society) 10/2014; 101(2). DOI:10.1136/heartjnl-2014-306013 · 6.02 Impact Factor