Predialysis Nephrology Care and Incident Atrial Fibrillation in Older Patients With ESKD Initiating Dialysis

Abstract

Background: Atrial fibrillation (AF) is common in patients with end-stage kidney disease (ESKD) on dialysis. Whether pre-ESKD nephrology care associates with AF is uncertain. Methods: We conducted a retrospective cohort study of older US patients ($67 years) with Medicare A&B who initiated dialysis (1996-2013) without a prior diagnosis of AF. Patients were categorized by the duration and number of predialysis nephrology outpatient visits. Patients were followed for 1 year for a new diagnosis of AF. We used multivariable Cox proportional hazards regression while accounting for the competing risks of kidney transplantation and death. Results: We identified 316,067 patients with ESKD initiating dialysis between 1996 and 2013 who had no prior AF diagnosis. In this cohort, 66.9% had any pre-ESKD outpatient nephrology care, with the first outpatient nephrology visit before dialysis initiation occurring at #6 months in 17.9%, 7 to 12 months in 9.4%, and >12 months in 39.6%. Outpatient pre-ESKD nephrology care for #6, 7 to 12, and >12 months versus none yielded adjusted cause-specific hazard ratios (HRs) of 0.87 (95% CI: 0.84-0.89), 0.83 (95% CI: 0.81-0.86), and 0.85 (95% CI: 0.83-0.87) for incident AF, respectively. Further, having 1 to 4 pre-ESKD outpatient nephrology visits, 5 to 9 visits, and $10 visits versus none yielded adjusted cause-specific HRs of 0.89 (95% CI: 0.86-0.91), 0.86 (95% CI: 0.83-0.88), and 0.81 (95% CI: 0.79-0.83), respectively. Conclusions: Having any predialysis nephrology care before initiation of dialysis was associated with slightly lower adjusted rates of incident AF over the first year of dialysis. The optimal timing and intensity of nephrology care to reduce the incidence of AF and other adverse health events requires further study.

Predialysis Care and Cardiovascular Outcomes: Why the Lead Up to Dialysis Matters

“…One alarming result from this article by Anumudu et al. 6 is that 33.1% of older patients in the United States have no outpatient nephrology exposure before initiating dialysis. Clearly, this lack of nephrology exposure has adverse cardiovascular consequences, but likely also limits patients’ education and options regarding dialysis modality, access creation, transplantation, and conservative care.…”

“…In this issue of Kidney International Reports , Anumudu et al. 6 address the following question: Can early and more frequent outpatient predialysis nephrology care serve as a preventive measure to reduce the incidence of atrial fibrillation once a patient initiates dialysis? This retrospective study used the US Renal Data System to identify more than 300,000 older patients (67 to 99 years old) without a prior Medicare billing claim for atrial fibrillation who initiated dialysis in the United States between 1996 and 2013.…”