Atrial Fibrillation Characteristics in Patients on Haemodialysis vs. Peritoneal Dialysis

Dialysis Modality, Transplant Characteristics, and Incident Atrial Fibrillation After Kidney Transplant: An Observational Study Using USRDS Data

Rationale & Objective

Atrial fibrillation is the most common arrhythmia and is increasing in prevalence. The prevalence of atrial fibrillation is high among patients receiving dialysis, affecting ∼21.3% of the patients receiving hemodialysis and 15.5% of those receiving peritoneal dialysis. The association of previous dialysis modality with incident atrial fibrillation in patients after receiving their first kidney transplant has not been studied.

Study Design

We used the United States Renal Data System to retrospectively identify adult, Medicare-insured patients who received their first kidney transplant between January 1, 2005, and September 30, 2012 and who had not previously been diagnosed with atrial fibrillation.

Setting & Participants

The study included 43,621 patients who were aged 18 years older when receiving a first kidney transplant between January 1, 2005, and September 30, 2012 and whose primary payer was Medicare (parts A and B) at the time of transplantation and the 6 months preceding it.

Exposure

Dialysis modality used before transplant.

Outcome

Time to incidence of atrial fibrillation up to 3 years posttransplant.

Analytical Approach

Multivariable Cox regression was used to estimate HRs.

Results

Of 43,621 patients, 84.9% received hemodialysis and 15.1% received peritoneal dialysis before transplant. The mean ± SD age was 51 ± 13.6 years; 60.8% were male, 55.6% White, and 35.8% Black race. The mean dialysis vintage was 4.3 ± 2.8 years. Newly diagnosed atrial fibrillation after kidney transplant occurred in 286 patients (during 15,363 person-years) who had received peritoneal dialysis and in 2,315 patients (during 83,536 person-years) who had received hemodialysis. After multivariable adjustment, atrial fibrillation was 20% (95% CI, 4%-38%) more likely in those who had been receiving hemodialysis versus peritoneal dialysis, regardless of whether death was considered a competing risk or a censoring event. Each year of pretransplant dialysis vintage increased the risk of posttransplant atrial fibrillation by 6% (95% CI, 3%-9%).

Limitations

Residual confounding; data from billing claims does not specify the duration of atrial fibrillation or whether it is valvular.

Conclusions

Pretransplant hemodialysis, as compared with peritoneal dialysis, was associated with higher risk of newly diagnosed atrial fibrillation after a first kidney transplant.

Plain-Language Summary

New-onset atrial fibrillation (AF) occurs in 7% of kidney transplant recipients in the first 3 years posttransplantation. We conducted this study to determine whether pretransplant dialysis modality was associated with posttransplant AF. We identified 43,621 patients; 84.9% used hemodialysis and 15.1% used peritoneal dialysis pretransplant. Multivariable Cox regression was used to estimate hazard ratios. We found that patients receiving hemodialysis pretransplant were at 20% increased risk of developing posttransplant AF as compared with patients receiving peritoneal dialysis. As our understanding of transplant-specific risk factors for AF increases, we may be able to better risk-stratify transplant patients and develop monitoring and management strategies that can improve outcomes.

Association between Hypertension and Atrial Fibrillation in Patients on Hemodialysis

This study aimed to evaluate the prevalence and the association between hypertension (HTN) and atrial fibrillation (AF) in hemodialysis (HD) patients. A chart review-based, cross-sectional study was conducted on HD patients who had received HD for at least 6 months. Demographic, hemodynamic, and laboratory data were retrieved from the BestCare system, and the main outcomes were blood pressure before and after dialysis, and the presence of AF. Our sample consisted of 304 HD patients; 162 (53%) were male, and the mean age was 63 ± 18 years. Sixty-eight (20%) had AF, of whom 44 (64.7%) were male, with a mean age of 73 ± 12 years. The risk of AF increased by 0.4 [odds ratio: 1.04; 95% confidence interval (CI): 1.02-1.06; P <0.001] for every year of age. Almost the entire sample (66.45%, n = 202) was hypertensive, and those patients had a mean age of 64 ± 17 years, and nearly one-third had a body mass index in the obese category (28.7%, n = 58). In addition, with every increase in the Charlson comorbidity index score by two points, there was a 40% increased risk of developing HTN (OR: 2.47; 95% CI: 1.17-5.18; P = 0.017). The risk factors for the development of HTN and AF in HD patients were found to be increasing age for AF and female sex for HTN. The presence of HTN and diabetes increased the risk of developing AF seven-fold after HD.

Elevated Troponin T and Enlarged Left Atrium Are Associated with the Incidence of Atrial Fibrillation in Patients with CKD Stage 4-5

INTRODUCTION

Atrial fibrillation (AF) and CKD are commonly coexisting conditions. However, data on epidemiology of AF in patients with CKD stage 4-5 is scarce.

METHODS

We prospectively enrolled 210 consecutive non-dialysis patients with CKD stage 4-5 between 2013 and 2017. Follow-up data on AF incidence along with medical history, laboratory tests, and echocardiography at baseline were gathered.

RESULTS

At baseline, mean age was 62 years, estimated glomerular filtration rate 12.8 mL/min, and 73/210 (34.8%) participants were female. Altogether, 41/210 (19.5%) patients had a previous diagnosis of AF. After median follow-up of 46 [IQR 27] months, new-onset AF occurred in 33/169 (19.5%) patients (69.9 events/1,000 person-years). In the Cox proportional hazard model, age >60 years (HR 4.27, CI 95% 1.57-11.64, p < 0.01), elevated troponin T (TnT) >50 ng/L (HR 3.61, CI 95% 1.55-8.37, p < 0.01), and left atrial volume index (LAVI) >30 mL/m2 (HR 4.82, CI 95% 1.11-21.00, p = 0.04) were independently associated with the incidence of new-onset AF.

CONCLUSION

The prevalence and incidence of AF was markedly high in this prospective study on patients with CKD stage 4-5. Elevated TnT and increased LAVI were independently associated with the occurrence of new-onset AF in patients with severe CKD.

Comparison of cardiovascular mortality in hemodialysis versus peritoneal dialysis

PURPOSE

Cardiovascular disease is a significant cause of morbidity and mortality in dialysis patients. With the increasing prevalence of dialysis patients, there is a need to systematically identify the epidemiology of cardiovascular disease in hemodialysis and peritoneal dialysis patients.

METHODS

A meta-analysis was conducted in reference to the MOOSE and PRISMA guidelines. Database searches were conducted on Medline and Embase on 17 March 2020. Meta-analysis of proportions was used to summarize the overall prevalence of events. Pairwise comparisons were used to compare between hemodialysis and peritoneal dialysis, and meta-regression was applied to identify the factors influencing disease.

RESULTS

A total of 28 studies were included in the review and prevalence of cardiovascular disease events including coronary artery disease, coronary artery complications, congestive heart failure, peripheral arterial disease, atrial fibrillation, and cardiovascular mortality were summarized. Atrial fibrillation (RR 1.287 CI 1.154-1.436, p < 0.001), congestive heart failure (RR 1.229 CI 1.074-1.407, p = 0.003), and peripheral arterial disease (RR 1.132 CI 1.021-1.255, p = 0.019) were more common in hemodialysis patients, but cardiovascular mortality was lower in hemodialysis relative to peritoneal dialysis patients. (RR 0.892 CI 0.828-0.960, p = 0.002).

CONCLUSION

The authors have found fewer cardiovascular events but higher cardiovascular mortality in patients on PD as compared to those on HD. Future research is required to establish the causality between dialysis modality and the cardiovascular outcomes described.

Anticoagulation in Patients with End-Stage Renal Disease and Atrial Fibrillation: Confusion, Concerns and Consequences

End-stage renal disease (ESRD) patients have a higher prevalence of diabetes mellitus, hypertension, congestive heart failure and advanced age, along with an increased incidence of non-valvular atrial fibrillation (AF), thereby increasing the risk for cerebrovascular accidents. Systemic anticoagulation is therefore recommended in patients with ESRD with AF to reduce the risk and complications from thromboembolism. Paradoxically, these patients are at an increased risk of bleeding due to great degree of platelet dysfunction and impaired interaction between platelet and endothelium. Currently, CHA2DS2-VASc and Hypertension, Abnormal liver/kidney function, Stroke, Bleeding, Labile INR, Elderly, Drugs or alcohol (HAS-BLED) are the recommended models for stroke risk stratification and bleeding risk assessment in patients with AF. There is conflicting data regarding benefits and risks of medications such as antiplatelet agents, warfarin and direct oral anticoagulants in ESRD patients with AF. Moreover, there is no randomized controlled trial data to guide the clinical decision making. Hence, a multi-disciplinary approach with annual re-evaluation of treatment goals and risk-benefit assessment has been recommended. In this article, we review the current recommendations with risks and benefits of anticoagulation in patients with ESRD with AF.

Atrial fibrillation and associated outcomes in patients with peritoneal dialysis and hemodialysis: a 14-year nationwide population-based study

BACKGROUND

Patients with end-stage renal disease (ESRD) undergoing dialysis have increased risks of atrial fibrillation (AF).

OBJECTIVE

To investigate dialysis-related incident AF and associated outcomes.

METHODS

Patients with dialysis were retrieved using data from Taiwan National Health Insurance Research Database during 2001-2013. Patients were separated into peritoneal dialysis (PD) and hemodialysis (HD) according to their initial modality. Primary outcome was new-onset AF. Secondary outcomes were AF-associated ischemic stroke (IS)/systemic embolism (SE) and hemorrhagic stroke.

RESULTS

A total of 158,910 dialytic patients were retrieved. After exclusion criteria, a total of 117,023 patients with ESRD undergoing dialysis were separated into 12,659 patients on PD and 104,364 patients on HD. There were 458 PD patients with subsequent development of AF, and 6216 HD patients with subsequent development of AF. At end of follow-up, patients on PD and HD had AF incidence densities of 7.8 and 8.8 events per 1000 person-years, the SHR of PD versus HD was 0.83 (95% CI 0.73-0.94). The SHR of PD versus HD was 1.07 (95% CI 0.80-1.44) for IS/SE and the SHR of PD versus HD was 0.34 (95% CI 0.13-0.90) for hemorrhagic stroke.

CONCLUSION

In patients with ESRD undergoing dialysis, PD had lowered risks of new onset of AF compared to HD. Subsequently, these AF patients in PD group had comparable incidence of ischemic stroke but decreased incidence of hemorrhagic stroke compared to AF patients in HD group. PD could be the most suitable modality in patients at risk for the onset of AF.

The influence of atrial fibrillation on the mortality of incident ESRD patients undergoing maintenance hemodialysis

Background

Atrial fibrillation (AF) is highly prevalent, occurring in 1%–2% of the adult population, increasing the risk of stroke, and resulting in considerable healthcare costs. While stroke is a major complication of AF, end-stage renal disease (ESRD) patients also have a high risk of stroke, suggesting that AF is a possible risk factor for mortality of ESRD patients. However, whether the existence of AF at the initiation of hemodialysis predicts higher mortality risk of incident ESRD patients remains to be defined.

Methods

This retrospective cohort study was performed at Wanfang Hospital from January 2004 to May 2018. The end points were mortality of patients or the end of the study. Incident ESRD patients who were on maintenance hemodialysis for more than 3 months were eligible for inclusion. Cox proportional regression and Kaplan–Meier survival curves were used to determine the association between predictors and mortality. The association between AF and echocardiographic parameters, causes of death were also investigated.

Results

Of the 393 incident ESRD patients at initiation of hemodialysis, 57 (14.5%) had AF and the median age was 71 years. Patients with AF were significantly older; showed significantly higher C-reactive protein levels, more heart failure, chronic obstructive pulmonary disease and mortality. Multivariate Cox regression showed that AF had a hazard ratio of 4.1 (95% confidence interval: 2.4–7.0) for mortality. Age-specific analysis showed that AF was significantly associated with mortality in all age groups. Echocardiography measurements including ejection fraction and left ventricular hypertrophy (LVH) were similar in AF and non-AF patients. Cause-specific analysis showed that AF significantly associated with overall cardiovascular death and death due to acute myocardial infarction/coronary artery disease and sepsis.

Conclusions

AF at the initiation of hemodialysis predicts higher mortality risk of incident ESRD patients regardless of age. The systolic function and degree of LVH were similar in AF and non-AF patients. The association between AF and sepsis-related death suggested the role of systemic inflammation on the pathogenesis of AF.

[Atrial Fibrillation in Patients on Dialysis Therapy: Epidemiology, Prognosis and Choice of Anticoagulant Therapy]

The review presents data on the prevalence of atrial fibrillation in patients on dialysis therapy. It is shown that dialysis-dependent patients with non-valve atrial fibrillation prognosis is extremely unfavorable, significantly increased risk of death due to both ischemic and hemorrhagic complications. Scales to assess the risk of thromboembolic and hemorrhagic complications in patients with atrial fibrillation on program dialysis are not validated. The lack of data from randomized clinical trials makes it much more difficult to choose anticoagulant therapy in patients with terminal stage of chronic kidney disease on dialysis who have undergone kidney transplantation. Therefore, the need for anticoagulant therapy and the choice of drugs in patients in this category should be made on the basis of a personalized multidisciplinary approach, taking into account comorbid pathology and the patient's preferences.

The Association of Atrial Fibrillation and Ischemic Stroke in Patients on Hemodialysis: A Competing Risk Analysis

Background

Stroke is common in patients with end-stage renal disease (ESRD) treated with hemodialysis (HD) and associated with high mortality rate. In the general population, atrial fibrillation (AF) is a major risk factor for stroke and therapeutic anticoagulation is associated with risk reduction, whereas in ESRD the relationship is less clear.

Objective

The purpose of this study is to demonstrate the influence of AF on stroke rates and probability in those on HD following competing risk analyses.

Design

A national record linkage cohort study.

Setting

All renal and stroke units in Scotland, UK.

Patients

All patients with ESRD receiving HD within Scotland from 2005 to 2013 (follow-up to 2015).

Measurements

Demographic, clinical, and laboratory data were linked between the Scottish Renal Registry, Scottish Stroke Care Audit, and hospital discharge data. Stroke was defined as a fatal or nonfatal event and mortality derived from national records.

Methods

Associations for stroke were determined using competing risk models: the cause-specific hazards model and the Fine and Gray subdistribution hazards model accounting for the competing risk of death in models of all stroke, ischemic stroke, and first-ever stroke.

Results

Of 5502 patients treated with HD with 12 348.6-year follow-up, 363 (6.6%) experienced stroke. The stroke incidence rate was 26.7 per 1000 patient-years. Multivariable regression on the cause-specific hazard for stroke demonstrated age, hazard ratio (HR) (95% confidence interval [CI]) = 1.04 (1.03-1.05); AF, HR (95% CI) = 1.88 (1.25-2.83); prior stroke, HR (95% CI) = 2.29 (1.48-3.54), and diabetes, HR (95% CI) = 1.92 (1.45-2.53); serum phosphate, HR (95% CI) = 2.15 (1.56-2.99); lower body weight, HR (95% CI) = 0.99 (0.98-1.00); lower hemoglobin, HR (95% CI) = 0.88 (0.77-0.99); and systolic blood pressure (BP), HR (95% CI) = 1.01 (1.00-1.02), to be associated with an increased stroke rate. In contrast, the subdistribution HRs obtained following Fine and Gray regression demonstrated that AF, weight, and hemoglobin were not associated with stroke risk. In both models, AF was significantly associated with nonstroke death.

Limitations

Our analyses derive from retrospective data sets and thus can only describe association not causation. Data on anticoagulant use are not available.

Conclusions

The incidence of stroke in HD patients is high. The competing risk of "prestroke" mortality affects the relationship between AF and risk of future stroke. Trial designs for interventions to reduce stroke risk in HD patients, such as anticoagulation for AF, should take account of competing risks affecting associations between risk factors and outcomes.

Long-term outcomes of dialysis in patients with chronic kidney disease and new-onset atrial fibrillation: A population-based cohort study

BACKGROUND

Chronic kidney disease (CKD) is associated with substantial cardiovascular morbidity. Atrial fibrillation (AF) is a prevalent arrhythmia that increases the risk of both stroke and cardiovascular mortality. Information about the mortality risk among patients with advanced CKD and new-onset AF (NAF) in the presence and absence of dialysis is important. However, the association between advanced CKD and NAF in patients with and without dialysis is unclear.

OBJECTIVE

To investigate long-term outcomes of the association between advanced CKD and NAF in patients with and without dialysis.

METHODS

We conducted a nested case-control study based on the National Health Insurance Program in Taiwan. Each participant aged 20 years and older who had CKD with dialysis from 2000 to 2013 was assigned to the dialysis group, whereas sex-, age-, CKD duration-, and index date-matched participants without dialysis were randomly selected and assigned to the non-dialysis group. We used the Cox regression model to estimate the hazard ratio (HR) with the 95% confidence interval (CI) for mortality in CKD patients with combined dialysis and NAF. Patients with neither NAF nor dialysis served as the reference group.

RESULTS

We identified 3,673 dialysis cases and 7,346 Non-dialysis matched controls for enrolment in the study. The crude mortality rates were 3.3 (95% CI: 3.1-3.5), 10.98 (95% CI: 9.3-13.0), 9.2 (95% CI: 8.7-10.0), and 18.0 (95% CI: 15.4-21.2) in the [Non-dialysis, non-NAF], [Non-dialysis, NAF], [Dialysis, non-NAF], and [Dialysis, NAF] groups, respectively. After adjustment for age, gender, and co-morbidities, the aHRs were 2.0 (95% CI: 1.7-2.3), 2.7 (95% CI: 2.5-2.9), and 3.5 (95% CI: 2.9-4.1) in the [Non-Dialysis, NAF], [Dialysis, non-NAF], and [Dialysis, NAF] groups compared with the [Non-Dialysis, non-NAF] group, respectively. The Kaplan-Meier survival curves showed the highest mortality risk in the [Dialysis, NAF] group among the study groups. Patients with concurrent peritoneal dialysis and AF had the highest mortality risk: aHR = 4.3 (95% CI: 2.3-8.0). However, there was a relatively lower effect of NAF on mortality in patients on dialysis than in patients who were not.

CONCLUSIONS

Patients with advanced CKD and NAF had a significantly increased risk of mortality. Dialysis is not risky for patients with concurrent CKD and NAF. Dialysis offers a sufficient survival benefit to be considered as a standard treatment, as indicated by the superior physical status of patients on dialysis.