Chronic kidney disease and atrial fibrillation: A dangerous combination

Abstract

Background Chronic kidney disease (CKD) and atrial fibrillation (AF) are both risk factors for bleeding, stroke and mortality. The aim of our study was to investigate the interaction between CKD and atrial fibrillation and outcomes. Methods We included 12,394 subjects referred to the University Medical Center Utrecht (the Netherlands) from September 1996 to February 2018 for an out-patient visit (Utrecht Cardiovascular Cohort Second Manifestation of Arterial disease cohort). Hazard ratios (HRs) with 95% confidence intervals (CIs) for bleeding, ischemic stroke or mortality were calculated with Cox proportional hazard analyses. Presence of interaction between AF and CKD was examined by calculating the relative excess risk due to interaction (RERI), the attributable proportion (AP) due to interaction and the synergy index (S). Results Of the 12,394 patients, 699 patients had AF, 2,752 patients had CKD and 325 patients had both AF and CKD. Patients with both CKD and AF had a 3.0-fold (95% CI 2.0–4.4) increased risk for bleeding, a 4.2-fold (95% CI 3.0–6.0) increased ischemic stroke risk and a 2.2-fold (95% CI 1.9–2.6) increased mortality risk after adjustment as compared with subjects without atrial fibrillation and CKD. We did not find interaction between AF and CKD for bleeding and mortality. However, we found interaction between AF and CKD for ischemic stroke risk (RERI 1.88 (95% CI 0.31–3.46), AP 0.45 (95% CI 0.17–0.72) and S 2.40 (95% CI 1.08–5.32)). Conclusion AF and CKD are both associated with bleeding, ischemic stroke and mortality. There is a positive interaction between AF and CKD for ischemic stroke risk, but not for bleeding or mortality.

Defining measures of kidney function in observational studies using routine health care data: methodological and reporting considerations

“…55 At least a fifth of the populations with CKD remain understudied and uncharacterized because they have CKD category G1 and G2 and require either A2 or greater urine albumin-to-creatinine ratio (UACR) or other signs of renal damage (e.g., structural kidney disease) for identification. 56,57 Recent initiatives have been taken to improve patient identification in routine databases by developing conversion formulas between urinary protein-creatinine ratio or urinary dipstick protein to UACR. 58,59 However, even these tests are not universally performed, and even if such conversion is introduced, the tests are not fully comparable.…”

The Cardio-Kidney Patient: Epidemiology, Clinical Characteristics and Therapy

“…Patients with both CKD and AF had a 3.0-fold (95% CI, 2.0-4.4) increased risk for bleeding, a 4.2-fold (95% CI, 3.0-6.0) increased ischemic stroke risk, and a 2.2-fold (95% CI, 1.9-2.6) increased mortality risk after adjustment as compared with subjects without atrial fibrillation and CKD. 83 No dedicated trials have been conducted in patients with atrial fibrillation with respect to rate control or rhythm control, and data need to be extrapolated from trials that excluded patients with CKD. A recent metaanalysis assessed the effect of CKD or hemodialysis on the recurrence of atrial fibrillation after catheter ablation.…”

“…Patients with both CKD and AF had a 3.0-fold (95% CI, 2.0–4.4) increased risk for bleeding, a 4.2-fold (95% CI, 3.0–6.0) increased ischemic stroke risk, and a 2.2-fold (95% CI, 1.9–2.6) increased mortality risk after adjustment as compared with subjects without atrial fibrillation and CKD. 83 …”

Anticoagulant Treatment in Patients with Atrial Fibrillation and Chronic Kidney Disease: Practical Issues

“…Both AF and CKD are associated with increased risk of stroke, bleeding events, and mortality, the prevention of which is of major concern in these particularly vulnerable patients. [10][11][12] To stratify the risk of stroke and systemic thromboembolism in AF patients, several clinical risk scores were developed, including the most commonly used the congestive heart failure, hypertension, age (at least 75 years), diabetes, stroke / transient ischemic attack / systemic embolism, vascular disease, age (65-74 years), sex category (female) (CHA 2 DS 2 -VASc) score since 2010, 11,13 which has been found to be a better predictor of ischemic stroke (C-index = 0.682) than the CHADS 2 score (C-index = 0.608) among patients with end-stage renal disease (ESRD) (P < .001) undergoing renal replacement therapy, without oral anticoagulants (OACs) or antiplatelet drugs. 14 Renal function has been incorporated in a modification of the scoring systems, including the R-CHA 2 DS 2 -VASc and R 2 -CHA 2 DS 2 -VASc scores, in which 1 or 2 points have been added to the original scores, respectively, in AF patients not receiving warfarin with eGFR < 60 mL/min/1.73 m 2 .…”