Prevalence of Atrial Fibrillation and Associated Factors in a Population of Long-Term Hemodialysis Patients

doi:10.1053/j.ajkd.2005.07.044

American Journal of Kidney Diseases

Volume 46, Issue 5, November 2005, Pages 897-902

https://doi.org/10.1053/j.ajkd.2005.07.044 Get rights and content

Background: Hemodialysis (HD) is associated with cardiovascular structural modifications; moreover, during HD, rapid electrolytic changes occur. Both factors may favor the onset of atrial fibrillation. Methods: To define the prevalence of atrial fibrillation and identify associated factors, 488 patients on long-term HD therapy (age, 66.6 ± 13.4 years; men, 58.0%; duration of HD, 76.5 ± 84.3 months) were studied. Results: Atrial fibrillation was reported in 27.0% of patients; paroxysmal in 3.5%, persistent in 9.6%, and permanent in 13.9%. Clinical and echocardiographic variables were considered: patients with atrial fibrillation were older (71.8 ± 9.3 versus 64.7 ± 14.2 years; P < 0.01), and its prevalence increased with age. Patients with arrhythmia had a longer duration of dialysis therapy (93.2 ± 100.5 versus 70.2 ± 76.7 months; P = 0.02). Atrial fibrillation was associated significantly with ischemic heart disease (P < 0.01), dilated cardiomyopathy (P < 0.01), acute pulmonary edema (P < 0.05), valvular disease (P < 0.05), cerebrovascular accidents (P < 0.05), and predialytic hyperkalemia (P < 0.05). Patients with atrial fibrillation more frequently showed left atrial dilatation (59.8% versus 34.5%; P < 0.0001), and in these subjects, left ventricular ejection fraction was significantly lower (53.9% versus 57.4%; P = 0.029). No association was found between arrhythmia and hypertension or diabetes. Multivariate analysis confirmed that patient age (P < 0.001), duration of HD therapy (P = 0.001), and left atrial dilatation (P < 0.001) were associated with atrial fibrillation. Conclusion: Atrial fibrillation is much more frequent in HD patients than in the general population; age, duration of HD history, presence of some heart diseases, and left atrial dilatation are associated with the arrhythmia.

Section snippets

Methods

From January until June 2003, charts of all HD patients from 5 dialysis centers in Lombardia, Italy, were revised. Based on these charts, an ad hoc data collection form was filled in for each patient by a team of 3 trained medical doctors in collaboration with referring nephrologists. Total number of patients treated at these centers at the time of data collection was 531. For 43 patients, echocardiographic data were not available. For this reason, data analysis has been performed considering

Results

AF was found in 132 patients (27.0%). The paroxysmal form was present in 17 patients (3.5%), and the persistent form, in 47 patients (9.6%), whereas AF was permanent in 68 patients (13.9%). For persistent AF episodes in which the cardioversion technique was described (n = 140), in 17% (n = 24), sinus rhythm was restored by electrical means of cardioversion, whereas in the other 116 episodes, cardioversion was performed pharmacologically. In the last group, the antiarrhythmic drug amiodarone was

Discussion

Main findings of this cross-sectional retrospective study are: (1) the high prevalence of AF in our HD population, and (2) the association of AF with patient age, duration of dialysis treatment, and LA dimension.

The present study is not the first to evaluate the prevalence of AF in HD patients.7, 8, 9 Previous studies showed a wide range of AF prevalence (7.0% to 23.4%). In our patients, AF is more frequent (27.0%) than in patients described in the study by Vazquez et al⁹ (13.6%), the most

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The net benefit of oral anticoagulation (OAC) with vitamin K antagonists or direct oral anticoagulants in patients with advanced chronic kidney disease and atrial fibrillation remains uncertain.
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In a retrospective cohort study, patients diagnosed with atrial fibrillation and eGFR of <30 mL/min/1.73 m² were identified in national Danish registers between 2010 and 2022. Initiation of OAC was identified based on redemption of a relevant prescription. One-year risks of thromboembolic event, major bleeding, and death associated with OAC and no treatment were computed and standardized to the distribution of risk factors in the sample based on hazards determined in multiple Cox regression models adjusted for age and sex.
A total of 3208 patients were included (mean age 80 years, 52.8% males, 20.9% chronic dialysis). OAC was initiated in 1375 (42.9%) patients, of whom 48.1% were vitamin K antagonists and 51.9% were direct oral anticoagulants. One-year risks in nontreated and anticoagulated patients were 4.8% (95% CI, 3.8%-5.7%) and 3.6% (95% CI, 2.8%-4.6%; P = .028) for thromboembolic event, 7.6% (95% CI, 6.6%-8.7%) and 10.5% (95% CI, 9.3%-12.1%; P < .001) for major bleeding, and 36.3% (95% CI, 34.2%-38.3%) and 29.6% (95% CI, 27.6%-31.6%; P < .001) for death, respectively.
In a retrospective study on patients with advanced chronic kidney disease and atrial fibrillation, OAC was associated with overall decreased 1-year risk of thromboembolic event and death offset by increased 1-year risk of major bleeding.
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Chronic kidney disease (CKD) is an independent risk factor for presenting atrial fibrillation (AF), which conditions an increased risk already present in CKD of suffering a thromboembolic event. And this risk is even higher in the hemodialysis (HD) population. On the other hand, in CKD patients and even more so in HD patients, the probability of suffering serious bleeding is also higher. Therefore, there is no consensus on whether or not to anticoagulate this population.
Taking as a model what is advised for the general population, the most common attitude among nephrologists has been to opt for anticoagulation, even though there is no randomized studies to support it.
Classically, anticoagulation has been done with vitamin K antagonists, at high cost for our patients: severe bleeding events, vascular calcification, and progression of nephropathy, among other complications.
With the emergence of direct-acting anticoagulants, a hopeful outlook was opened in the field of anticoagulation, as they were postulated as more effective and safer drugs than antivitamin K. However, in clinical practice, this has not been the case.
In this paper we review various aspects of AF and its anticoagulant treatment in the HD population.
La enfermedad renal crónica (ERC) es un factor de riesgo independiente para presentar fibrilación auricular (FA) lo que condiciona un incremento del riesgo ya presente en la ERC de sufrir un evento tromboembólico; y este riesgo es mayor aún en la población en hemodiálisis (HD). Por otro lado, en estos pacientes también es mayor la probabilidad de sufrir una hemorragia grave. Por ello, decidir si se debe anticoagular o no a un paciente con FA en diálisis es motivo de controversia entre la comunidad nefrológica.
Tomando como modelo lo aconsejado para la población general, la actitud más común entre los nefrólogos ha sido la de optar por la anticoagulación, pese a que no haya estudios randomizados que lo apoyen.
Clásicamente la anticoagulación se ha hecho con antagonistas de la vitamina K, con alto coste para nuestros pacientes: eventos hemorrágicos graves, calcificación vascular y progresión de la nefropatía entre otras complicaciones.
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Atrial fibrillation (AF) is the most common arrhythmia in patients undergoing hemodialysis (HD); AF lowers quality of life (QoL) and increases the risk of dialysis-related complications. The present study aimed to evaluate the effectiveness of AF ablation on the QoL in patients undergoing HD.
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La fibrillation auriculaire (FA), la forme d’arythmie la plus fréquente chez les patients sous hémodialyse (HD), entraîne une diminution de la qualité de vie (QdV) et une augmentation des risques de complications liées à la dialyse. La présente étude visait à évaluer l’effet de l’ablation de la FA sur la QdV des patients sous HD.
Dix-neuf patients sous HD (âgés de 68 ± 8 ans, dont 14 étaient des hommes et 15 étaient atteints de FA paroxystique) ayant subi une ablation par cathéter de la FA ont été admis dans l’étude. Le questionnaire KDQOL-SF (Kidney Disease Quality of Life Short Form) a été utilisé pour évaluer la QdV des patients sous HD avant l’intervention et six mois après l’ablation. L’issue de l’ablation et les complications liées à l’intervention ont été évaluées et comparées à celles de 1 053 patients consécutifs n’étant pas hémodialysés et ayant subi une ablation de la FA.
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L’ablation par cathéter de la FA permet d’améliorer la QdV des patients qui subissent un traitement par HD de longue durée.
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Atrial fibrillation (AF) is a common arrhythmia in patients with hypertrophic cardiomyopathy (HCM) and is associated with renal function deterioration. The protective effects of catheter ablation (CA) of AF on renal function in patients with HCM remain unsolved. From 2009 to 2020, a total of 169 consecutive patients with HCM and AF (age 70 ± 12, 87 males) were retrospectively evaluated. The estimated glomerular filtration rate (eGFR) was evaluated at the study enrollment or 1 month before the CA and reevaluated 3 and 12 months later. In the 169 patients, 63 underwent CA of AF (ablation group), and the remaining 106 did not (control group). After propensity score matching, 45 pairs were matched. The baseline eGFR was similar between the 2 groups (p = 0.83). During a mean follow-up period of 34 ± 27 months, sinus rhythm was maintained in 36 patients (80%) after 1.7 ± 0.8 ablation procedures. The eGFR significantly decreased from baseline to 3 months (p <0.01) and from baseline to 1 year (p <0.01) in the control group, whereas the eGFR in the ablation group was maintained both from baseline to 3 months (p = 0.94) and from baseline to 1 year (p = 1.00) after the CA. The change in the eGFR between baseline and 12 months was significantly smaller in the ablation group than in the control group (p <0.01). After logistic regression analysis, CA of AF was the independent predictor of an improvement of eGFR (odds ratio 2.81, 95% confidence interval 1.08 to 7.36, p = 0.04). In conclusion, CA of AF had a protective effect on renal function in patients with HCM.
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Citation Excerpt :
Chronic kidney disease (CKD) is associated with an increased risk of atrial fibrillation (AF).1,2 The prevalence increases from 16% - 21% in non-dialysis3-5 to 15% - 40% in dialysis dependent patients.6-11 These two diseases often coexist and are commonly found in clinical practice because they both share common risk factors, such as old age, hypertension, diabetes, smoking, obesity, physical inactivity and heart failure.12
Chronic kidney disease (CKD) is associated with increased risk of stroke, major bleeding, morbidity and overall mortality in atrial fibrillation patients. The aim of this study is to demonstrate the effect of different eGFR strata and the TTR on clinical outcomes in AF patients with CKD.NVAF patients were consecutively enrolled from hospitals across Thailand. eGFR were categorized into three different eGFR categories; eGFR >60, 30-59 and <30 mL/min/1.73 m². TTR values were also categorized into TTR >75%, TTR 60-75 and TTR <60%. We identified 1,739 patients who received warfarin. Among patients who acquired TTR<60, those with eGFR <30 ml/min/1.73 m² demonstrated the highest stroke/SSE rate of 8.5% (P<0.001). Patients with eGFR <30 ml/min/1.73 m², in addition to the presence of TTR<60, were at the highest risk to developing major bleeding with the rate of 17.9% (p <0.001). However, intracranial hemorrhage (ICH) appeared towards increasing rate with the combination of eGFR at even <60 ml/min/1.73 m² and TTR <60. Death was also considerably high with the rate of 17.9% in patients with the combination of TTR <60 and eGFR <30 ml/min/1.73 m². Severe CKD resulted in higher risks of stroke/SSE, major bleeding and death in patients with low TTR. Patients with TTR >60, especially TTR >75%, is associated with reduced risk of stroke/SSE, major bleeding and death irrespective of eGFR level. The combination of low TTR <60 and eGFR level less than 60 ml/min/1.73 m² substantially increased risks of all cardiovascular outcomes.

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: Originally published online as doi:10.1053/j.ajkd.2005.07.044 on September 23, 2005

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Original InvestigationDialysis TherapyPrevalence of Atrial Fibrillation and Associated Factors in a Population of Long-Term Hemodialysis Patients

Section snippets

Methods

Results

Discussion

Am J Cardiol

Kidney Int

Kidney Int Suppl

Am Heart J

Am Heart J

Am J Cardiol

Kidney Int

Relationships between sinus rhythm, treatment, and survivalThe Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Study

Circulation

Original Investigation
Dialysis Therapy
Prevalence of Atrial Fibrillation and Associated Factors in a Population of Long-Term Hemodialysis Patients