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Heo GY, Park JT, Kim HJ, Kim KW, Kwon YU, Kim SH, Kim GO, Han SH, Yoo TH, Kang SW, Kim HW. Adequacy of Dialysis and Incidence of Atrial Fibrillation in Patients Undergoing Hemodialysis. Circ Cardiovasc Qual Outcomes 2024; 17:e010595. [PMID: 38873761 DOI: 10.1161/circoutcomes.123.010595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 05/17/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Atrial fibrillation (AF) can lead to stroke, heart failure, and mortality and has a greater prevalence in dialysis patients than in the general population. Several studies have suggested that uremic toxins may contribute to the development of AF. However, the association between dialysis adequacy and incident AF has not been well established. METHODS In this retrospective nationwide cohort study, we analyzed data from the Korean National Periodic Hemodialysis Quality Assessment from 2013 to 2015 of patients who received outpatient maintenance hemodialysis 3× a week. The main exposure was single pooled Kt/V (spKt/V), which is the dialysis adequacy index, and the primary outcome was the development of AF. For the primary analysis, patients were categorized into quartiles according to baseline spKt/V. The lowest quartile, representing the lowest adequacy, was used as the reference group. Fine-Gray subdistribution hazard models were used, treating all-cause mortality as a competing risk. RESULTS Of 25 173 patients, the mean age was 60 (51-69) years, and 14 772 (58.7%) were men. During a median follow-up of 5.7 years, incident AF occurred in a total of 3883 (15.4%) patients. Participants with a higher spKt/V tended to have lower AF incidence. In survival analysis, a graded association was observed between the risk of incident AF and spKt/V quartiles: subdistribution hazard ratios and 95% CIs for the second, third, and the highest quartile compared with the lowest quartile were 0.90 (95% CI, 0.82-0.98), 0.84 (95% CI, 0.77-0.93), and 0.79 (95% CI, 0.72-0.88), respectively. CONCLUSIONS This nationwide cohort study showed that a higher spKt/V is associated with a reduced risk of incident AF. These findings suggests that reducing uremic toxin burden through enhanced dialysis clearance may be associated with a lower risk of AF development in patients undergoing maintenance hemodialysis.
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Affiliation(s)
- Ga Young Heo
- Department of Internal Medicine, Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, Republic of Korea (G.Y.H., J.T.P., S.H.H., T.-H.Y., S.-W.K., H.W.K.)
| | - Jung Tak Park
- Department of Internal Medicine, Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, Republic of Korea (G.Y.H., J.T.P., S.H.H., T.-H.Y., S.-W.K., H.W.K.)
| | - Hyo Jeong Kim
- Division of Nephrology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University, College of Medicine, Seoul, Republic of Korea (H.J.K.)
| | - Kyung Won Kim
- Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea (K.W.K.)
| | - Yong Uk Kwon
- Healthcare Review and Assessment Committee, Health Insurance Review and Assessment Service, Wonju, South Korea (Y.U.K.)
| | - Soo Hyun Kim
- Quality Assessment Department, Health Insurance Review and Assessment Service, Wonju, South Korea (S.H.K.)
| | - Gui Ok Kim
- Quality Assessment Management Division, Health Insurance Review and Assessment Service, Wonju, South Korea (G.O.K.)
| | - Seung Hyeok Han
- Department of Internal Medicine, Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, Republic of Korea (G.Y.H., J.T.P., S.H.H., T.-H.Y., S.-W.K., H.W.K.)
| | - Tae-Hyun Yoo
- Department of Internal Medicine, Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, Republic of Korea (G.Y.H., J.T.P., S.H.H., T.-H.Y., S.-W.K., H.W.K.)
| | - Shin-Wook Kang
- Department of Internal Medicine, Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, Republic of Korea (G.Y.H., J.T.P., S.H.H., T.-H.Y., S.-W.K., H.W.K.)
| | - Hyung Woo Kim
- Department of Internal Medicine, Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, Republic of Korea (G.Y.H., J.T.P., S.H.H., T.-H.Y., S.-W.K., H.W.K.)
- Institute for Innovation in Digital Healthcare, Yonsei University, Seoul, Republic of Korea (H.W.K.)
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2
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Genovesi S, Camm AJ, Covic A, Burlacu A, Meijers B, Franssen C, Luyckx V, Liakopoulos V, Alfano G, Combe C, Basile C. Treatment strategies of the thromboembolic risk in kidney failure patients with atrial fibrillation. Nephrol Dial Transplant 2024; 39:1248-1257. [PMID: 38816212 PMCID: PMC11288792 DOI: 10.1093/ndt/gfae121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Indexed: 06/01/2024] Open
Abstract
The incidence and prevalence of atrial fibrillation (AF) in patients affected by kidney failure, i.e. glomerular filtration rate <15 ml/min/1.73 m2, is high and probably underestimated. Numerous uncertainties remain regarding how to prevent thromboembolic events in this population because both cardiology and nephrology guidelines do not provide clear recommendations. The efficacy and safety of oral anticoagulant therapy (OAC) in preventing thromboembolism in patients with kidney failure and AF has not been demonstrated for either vitamin K antagonists (VKAs) or direct anticoagulants (DOACs). Moreover, it remains unclear which is more effective and safer, because estimated creatinine clearance <25-30 ml/min was an exclusion criterion in the randomized controlled trials (RCTs). Three RCTs comparing DOACs and VKAs in kidney failure failed to reach the primary endpoint, as they were underpowered. The left atrial appendage is the main source of thromboembolism in the presence of AF. Left atrial appendage closure (LAAC) has recently been proposed as an alternative to OAC. RCTs comparing the efficacy and safety of LAAC versus OAC in kidney failure were terminated prematurely due to recruitment failure. A recent prospective study showed a reduction in thromboembolic events in haemodialysis patients with AF and undergoing LAAC compared with patients taking or not taking OAC. We review current treatment standards and discuss recent developments in managing the thromboembolic risk in kidney failure patients with AF. The importance of shared decision-making with the multidisciplinary team and the patient to consider individual risks and benefits of each treatment option is underlined.
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Affiliation(s)
- Simonetta Genovesi
- School of Medicine and Surgery, University of Milano-Bicocca, Nephrology Clinic, Monza, Italy
- Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - A John Camm
- St. George's University of London, London, UK
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center – ‘C.I. Parhon’ University Hospital and 'Grigore T. Popa’ University of Medicine, Iasi, Romania
| | - Alexandru Burlacu
- Nephrology Clinic, Dialysis and Renal Transplant Center – ‘C.I. Parhon’ University Hospital and 'Grigore T. Popa’ University of Medicine, Iasi, Romania
| | - Björn Meijers
- Nephrology Unit, University Hospitals Leuven and Department of Microbiology, Immunology and Organ Transplantation, KU Leuven, Leuven, Belgium
| | - Casper Franssen
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Valerie Luyckx
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Paediatrics and Child Health, University of Cape Town, South Africa
- Department of Public and Global Health, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Vassilios Liakopoulos
- Second Department of Nephrology, AHEPA University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Gaetano Alfano
- Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
| | - Christian Combe
- Department of Nephrology, CHU de Bordeaux and INSERM U1026, University of Bordeaux, Bordeaux, France
| | - Carlo Basile
- Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy
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3
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Onishi N, Kaitani K, Nakagawa Y, Kobori A, Inoue K, Kurotobi T, Morishima I, Matsui Y, Yamaji H, Nakazawa Y, Kusano K, Shimizu Y, Hanazawa K, Tamura T, Izumi C, Morimoto T, Ono K, Kimura T, Shizuta S. Radiofrequency Catheter Ablation for Atrial Fibrillation Patients on Hemodialysis (From the Kansai Plus Atrial Fibrillation Registry) - Clinical Impact of Early Recurrence. Circ J 2024; 88:1057-1064. [PMID: 38199253 DOI: 10.1253/circj.cj-23-0671] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
BACKGROUND Catheter ablation (CA) for atrial fibrillation (AF) in patients on hemodialysis (HD) is reported to have a high risk of late recurrence (LR). However, the relationship between early recurrence (ER) within a 90-day blanking period after CA in AF patients and LR in HD patients remains unclear. METHODS AND RESULTS Of the 5,010 patients in the Kansai Plus Atrial Fibrillation Registry, 5,009 were included in the present study. Of these patients, 4,942 were not on HD (non-HD group) and 67 were on HD (HD group). HD was an independent risk factor for LR after the initial CA (adjusted hazard ratio 1.6; 95% confidence interval 1.1-2.2; P=0.01). In patients with ER, the rate of sinus rhythm maintenance at 3 years after the initial CA was significantly lower in the HD than non-HD group (11.4% vs. 35.4%, respectively; log-rank P=0.004). However, in patients without ER, there was no significant difference in the rate of sinus rhythm maintenance at 3 years between the HD and non-HD groups (67.7% vs. 74.5%, respectively; log-rank P=0.62). CONCLUSIONS ER in HD patients was a strong risk factor for LR. However, even HD patients could expect a good outcome without ER after the initial CA.
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Affiliation(s)
- Naoaki Onishi
- Division of Cardiology, Japanese Red Cross Otsu Hospital
- Department of Cardiology, Tenri Hospital
| | - Kazuaki Kaitani
- Division of Cardiology, Japanese Red Cross Otsu Hospital
- Department of Cardiology, Tenri Hospital
| | - Yoshihisa Nakagawa
- Department of Cardiology, Tenri Hospital
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Atsushi Kobori
- Division of Cardiology, Kobe City Medical Center General Hospital
| | - Koichi Inoue
- Cardiovascular Center, Sakurabashi Watanabe Hospital
- Division of Cardiology, National Hospital Organization Osaka National Hospital
| | - Toshiya Kurotobi
- Cardiovascular Center, Shiroyama Hospital
- Cardiovascular Center, Namba Kurotobi Heart Clinic
| | | | - Yumie Matsui
- Department of Cardiology, Saiseikai Izuo Hospital
| | | | - Yuko Nakazawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yukiko Shimizu
- Department of Cardiology, Tenri Hospital
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Koji Hanazawa
- Department of Cardiology, Tenri Hospital
- Division of Arrhythmia and Electrophysiology, Nishinomiya Watanabe Cardiovascular Center
| | | | - Chisato Izumi
- Department of Cardiology, Tenri Hospital
- Department of Heart Failure and Transplantation, National Cerebral and Cardiovascular Center
| | | | - Koh Ono
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
- Department of Cardiology, Hirakata Kosai Hospital
| | - Satoshi Shizuta
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
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4
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Schlieper G. [Atrial fibrillation - what should be taken into account with chronic kidney disease and hemodialysis?]. Dtsch Med Wochenschr 2024; 149:724-727. [PMID: 38781997 DOI: 10.1055/a-2149-4290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
CKD is a common comorbidity in patients with atrial fibrillation. The CHA2DS2-VASc score is not validated in patients with severe CKD and has a low predictive value in dialysis patients. As NOACs are partly eliminated by the kidneys the dosage has to be adapted in CKD. Recent studies indicate an acceptable safety profile for NOACs in CKD. However, larger randomized studies are still lacking. The results from prospective studies with placebo i.e., no anticoagulation therapy, are pending.
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Affiliation(s)
- Georg Schlieper
- Zentrum für Nieren-, Hochdruck- und Stoffwechselerkrankungen, Hannover
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5
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Maragkoudakis S, Tzanakis I, Mamaloukaki M, Damianakis N, Michelakis E, Marketou M, Vittorakis E, Sideras E, Katsi V, Kochiadakis G. Oxygen venous saturation is associated with subclinical myocardial systolic dysfunction in patients with end-stage renal disease undergoing hemodialysis. Arch Med Sci Atheroscler Dis 2024; 9:e94-e101. [PMID: 39086619 PMCID: PMC11289276 DOI: 10.5114/amsad/188091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 04/29/2024] [Indexed: 08/02/2024] Open
Abstract
Introduction The aim of this prospective study was to evaluate the impact of hemodialysis (HD) on myocardial injury, of both right and left ventricle function as well as their association with venous oxygen saturation (ScvO2) alterations. Material and methods We included in the study stable consecutive patients with end-stage renal disease (ESRD) undergoing regular HD. Right and left ventricular speckle-tracking echocardiographies were performed in all patients. The examination calculates the global systolic longitudinal strain (GLS). Blood samples were obtained from the central vein in order to measure the O2 saturation (ScvO2) levels prior and post HD. High sensitive troponin (HST) was also measured in all patients before and after HD. Results Thirty seven patients were evaluated. We found that both mean ScvO2 and left ventricle GLS (LV GLS) were deteriorated after the dialysis session: 76.47 ±1.98 to 71.54 ±5.10, p < 0.05 and -17.73 ±3.44 to -14.21 ±3.44%, p < 0.01, respectively. HST levels were increased at the end of hemodialysis, 22.45 ±13.26 to 106.78 ±146.19 pg/ml, p < 0.01. A significant correlation was also found between the decrease of LV GLS with the ScvO2 reduction, p = 0.001, as well as with the increase of the HST levels, p = 0.001. Conclusions Our data demonstrate that there is a significant worsening of the GLS of the left ventricle at the end of the dialysis, which is strongly associated with the concomitant deterioration of ScvO2. The may be a reliable index of circulatory stress indicating a subclinical myocardial dysfunction during HD.
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Affiliation(s)
| | - Ioannis Tzanakis
- Nephrology Department of General Hospital of Chania, Chania, Greece
| | | | | | | | - Maria Marketou
- First Cardiology Department, School of Medicine, Hippokrateion General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Vasiliki Katsi
- First Cardiology Department, School of Medicine, Hippokrateion General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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6
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Reaves AC, Weiner DE, Sarnak MJ. Home Dialysis in Patients with Cardiovascular Diseases. Clin J Am Soc Nephrol 2024:01277230-990000000-00337. [PMID: 38198166 DOI: 10.2215/cjn.0000000000000410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 12/18/2023] [Indexed: 01/11/2024]
Abstract
Kidney failure with replacement therapy and cardiovascular disease are frequently comorbid. In patients with kidney failure with replacement therapy, cardiovascular disease is a major contributor to morbidity and mortality. Conventional thrice-weekly in-center dialysis confers risk factors for cardiovascular disease, including acute hemodynamic fluctuations and rapid shifts in volume and solute concentration. Home hemodialysis and peritoneal dialysis (PD) may offer benefits in attenuation of cardiovascular disease risk factors primarily through improved volume and BP control, reduction (or slowing progression) of left ventricular mass, decreased myocardial stunning, and improved bone and mineral metabolism. Importantly, although trial data are available for several of these risk factors for home hemodialysis, evidence for PD is limited. Among patients with prevalent cardiovascular disease, home hemodialysis and PD may also have potential benefits. PD may offer particular advantages in heart failure given it removes volume directly from the splanchnic circulation, thus offering an efficient method of relieving intravascular congestion. PD also avoids the risk of blood stream infections in patients with cardiac devices or venous wires. We recognize that both home hemodialysis and PD are also associated with potential risks, and these are described in more detail. We conclude with a discussion of barriers to home dialysis and the critical importance of interdisciplinary care models as one component of advancing health equity with respect to home dialysis.
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Affiliation(s)
- Allison C Reaves
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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7
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Genovesi S, Porcu L, Rebora P, Slaviero G, Casu G, Bertoli S, Airoldi F, Buskermolen M, Gallieni M, Pieruzzi F, Rovaris G, Montoli A, Piccaluga E, Molon G, Alberici F, Adamo M, Gaspardone A, D'Angelo G, Merella P, Vezzoli G, Trezzi B, Mazzone P. Long-term safety and efficacy of left atrial appendage occlusion in dialysis patients with atrial fibrillation: a multi-center, prospective, open label, observational study. Clin Kidney J 2023; 16:2683-2692. [PMID: 38046009 PMCID: PMC10689152 DOI: 10.1093/ckj/sfad221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Indexed: 12/05/2023] Open
Abstract
Background The prevalence of atrial fibrillation (AF) in end stage kidney disease (ESKD) patients undergoing dialysis is high, however, the high risk of bleeding often hampers with a correct anticoagulation in ESKD patients with AF, despite high thromboembolic risk. Left atrial appendage (LAA) occlusion is a anticoagulation (OAT) for thromboembolism prevention in AF populations with high hemorrhagic risk. Methods and Results The purpose of the study was to evaluate the efficacy and safety of LAA occlusion in a cohort of dialysis patients undergoing the procedure (LAA occlusion cohort, n = 106), in comparison with two other ESKD cohorts, one taking warfarin (Warfarin cohort, n = 114) and the other without anticoagulation therapy (No-OAT cohort, n = 148). After a median follow-up of 4 years, a Cox regression model, adjusted for possible confounding factors, showed that the hazard ratios (HRs) of thromboembolic events in the LAA occlusion cohort were 0.19 (95%CI 0.04-0.96; p = 0.045) and 0.16 (95%CI 0.04-0.66; p = 0.011) as compared with Warfarin and No-OAT cohorts, respectively. The HR of bleeding in the LAA occlusion cohort was 0.37 (95%CI 0.16-0.83; p = 0.017) compared to Warfarin cohort, while there were no significant differences between the LAA occlusion and the No-OAT cohort (HR 0.51; 95%CI 0.23-1.12; p = 0.094). Adjusted Cox regression models showed lower mortality in patients undergoing LAA occlusion as compared with both the Warfarin cohort (HR 0.60; 95%CI 0.38-0.94; p = 0.027) and no-OAT cohort (HR 0.52; 95%CI 0.34-0.78; p = 0.002). Thromboembolic events in the LAA occlusion cohort were lower than expected according to the CHA2DS2VASc score (1.7 [95%CI 0.3-3.0] vs 6.7 events per 100 person/years, p < 0.001). Conclusion In ESKD patients with AF, LAA occlusion is safe and effective and is associated with reduced mortality compared with OAT or no therapy.
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Affiliation(s)
- Simonetta Genovesi
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Luca Porcu
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
| | - Paola Rebora
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | | | - Gavino Casu
- Cardiology Unit, Azienda Ospedaliera Universitaria di Sassari, Sassari, Italy
| | - Silvio Bertoli
- Dialysis and Nephrology Unit-IRCCS-Multimedica, Sesto S.Giovanni, Italy
| | - Flavio Airoldi
- Electrophysiology Unit-IRCCS-Multimedica, Sesto S.Giovanni, Italy
| | | | - Maurizio Gallieni
- Nephrology and Dialysis Unit, ASST Fatebenefratelli Sacco, Milano, Italy
- Department of Biomedical and Clinical Sciences, University of Milano, Milano, Italy
| | - Federico Pieruzzi
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Giovanni Rovaris
- Interventional Electrophysiology Unit, San Gerardo Hospital, Monza, Italy
| | | | | | - Giulio Molon
- Cardiology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Federico Alberici
- Nephrology Unit, ASST degli Spedali Civili di Brescia, Brescia, Italy
| | - Marianna Adamo
- Cardiology Unit, ASST degli Spedali Civili di Brescia, Brescia, Italy
| | | | | | - Pierluigi Merella
- Cardiology Unit, Azienda Ospedaliera Universitaria di Sassari, Sassari, Italy
| | | | - Barbara Trezzi
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Patrizio Mazzone
- Cardiology 3, “A. De Gasperis” Cardio Center, ASST GOM Niguarda Ca' Granda, Milan, Italy
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8
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Junho CVC, Frisch J, Soppert J, Wollenhaupt J, Noels H. Cardiomyopathy in chronic kidney disease: clinical features, biomarkers and the contribution of murine models in understanding pathophysiology. Clin Kidney J 2023; 16:1786-1803. [PMID: 37915935 PMCID: PMC10616472 DOI: 10.1093/ckj/sfad085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Indexed: 11/03/2023] Open
Abstract
The cardiorenal syndrome (CRS) is described as a multi-organ disease encompassing bidirectionally heart and kidney. In CRS type 4, chronic kidney disease (CKD) leads to cardiac injury. Different pathological mechanisms have been identified to contribute to the establishment of CKD-induced cardiomyopathy, including a neurohormonal dysregulation, disturbances in the mineral metabolism and an accumulation of uremic toxins, playing an important role in the development of inflammation and oxidative stress. Combined, this leads to cardiac dysfunction and cardiac pathophysiological and morphological changes, like left ventricular hypertrophy, myocardial fibrosis and cardiac electrical changes. Given that around 80% of dialysis patients suffer from uremic cardiomyopathy, the study of cardiac outcomes in CKD is clinically highly relevant. The present review summarizes clinical features and biomarkers of CKD-induced cardiomyopathy and discusses underlying pathophysiological mechanisms recently uncovered in the literature. It discloses how animal models have contributed to the understanding of pathological kidney-heart crosstalk, but also provides insights into the variability in observed effects of CKD on the heart in different CKD mouse models, covering both "single hit" as well as "multifactorial hit" models. Overall, this review aims to support research progress in the field of CKD-induced cardiomyopathy.
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Affiliation(s)
| | - Janina Frisch
- Department of Biophysics, Center for Integrative Physiology and Molecular Medicine, Medical Faculty, Saarland University, Center for Human and Molecular Biology, Homburg/Saar, Germany
| | - Josefin Soppert
- Institute for Molecular Cardiovascular Research (IMCAR), University Hospital RWTH Aachen, Aachen, Germany
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Julia Wollenhaupt
- Institute for Molecular Cardiovascular Research (IMCAR), University Hospital RWTH Aachen, Aachen, Germany
| | - Heidi Noels
- Institute for Molecular Cardiovascular Research (IMCAR), University Hospital RWTH Aachen, Aachen, Germany
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
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9
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Law MM, Tan SJ, Wong MC, Toussaint ND. Atrial Fibrillation in Kidney Failure: Challenges in Risk Assessment and Anticoagulation Management. Kidney Med 2023; 5:100690. [PMID: 37547561 PMCID: PMC10403723 DOI: 10.1016/j.xkme.2023.100690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Abstract
Management of atrial fibrillation (AF) is a clinical conundrum in people with kidney failure. Stroke risk is disproportionately high, but clinicians have a limited armamentarium to improve outcomes in this population in whom there is a concurrently high bleeding risk. Direct oral anticoagulants may have a superior benefit-risk profile compared with vitamin K antagonists in people on hemodialysis. Although research has predominantly focused on identifying a safe and effective oral anticoagulation option to reduce stroke risk in people with kidney failure (and predominantly those on hemodialysis), it remains uncertain how clinicians discriminate between people who would derive net clinical benefit as opposed to net harm. The recommended CHA2DS2-VASc score cutoffs provide poor discriminatory value, and there is an urgent need to identify robust markers of thromboembolic risk in kidney failure. There is increasing data to challenge the prior dogma of risk equivalence across AF type, and the American Heart Association highlights moving beyond AF as a binary entity to consider the prognostic significance of AF burden. Implantable cardiac monitor studies reveal high rates and varied burden of subclinical and paroxysmal AF in people on hemodialysis. The association between AF burden and the proarrhythmic environment of hemodialysis with cyclical volume loading, offloading, and electrolyte changes is not well studied. We review the significance of AF burden as a contributor to thromboembolic risk, its potential as the missing link in risk assessment, and updated evidence for anticoagulation in people with kidney failure.
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Affiliation(s)
- Mandy M. Law
- Department of Nephrology, the Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Sven-Jean Tan
- Department of Nephrology, the Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Michael C.G. Wong
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Department of Cardiology, the Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Nigel D. Toussaint
- Department of Nephrology, the Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
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10
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Nam KW, Kim CK, Yu S, Oh K, Chung JW, Bang OY, Kim GM, Jung JM, Song TJ, Kim YJ, Kim BJ, Heo SH, Park KY, Kim JM, Park JH, Choi JC, Park MS, Kim JT, Choi KH, Hwang YH, Seo WK. D-dimer to fibrinogen ratio predicts early neurological deterioration in ischemic stroke with atrial fibrillation. Thromb Res 2023; 229:219-224. [PMID: 37562164 DOI: 10.1016/j.thromres.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/19/2023] [Accepted: 07/28/2023] [Indexed: 08/12/2023]
Abstract
INTRODUCTION The D-dimer to fibrinogen ratio (DFR) is a good indicator of clot-producing activity in thrombotic disease, but its clinical usefulness in stroke patients with nonvalvular atrial fibrillation (NVAF) has not been studied. We evaluated the association between the DFR and early neurological deterioration (END) in acute ischemic stroke (AIS) patients with NVAF. METHODS We included consecutive AIS patients with NVAF between 2013 and 2015 from the registry of a real-world prospective cohort from 11 large centers in South Korea. END was defined as an increase ≥2 in the total NIHSS score or ≥ 1 in the motor NIHSS score within the first 72 h of admission. The DFR was calculated as follows: DFR = D-dimer (mg/L)/fibrinogen (mg/dL) x 100. RESULTS A total of 1018 AIS patients with NVAF were evaluated. In multivariable logistic regression analysis, the highest DFR tertile was closely associated with END (adjusted odds ratio [aOR] = 2.14, 95 % confidence interval [CI]: 1.24-3.69). Hypertension (aOR = 1.71, 95 % CI: 1.09-2.70), initial NIHSS score (aOR = 1.05, 95 % CI: 1.02-1.07) and use of anticoagulants (aOR = 0.41, 95 % CI: 0.28-0.60) were also correlated with END. In addition to END, the DFR was correlated with discharge NIHSS and modified Rankin Scale (mRS) scores and the 3-month mRS score. CONCLUSIONS High DFR values were associated with END in AIS patients with NVAF. As the DFR is an indicator directly related to the main pathological mechanism of NVAF patients (fibrinolysis and coagulation), it may be useful in predicting their prognosis.
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Affiliation(s)
- Ki-Woong Nam
- Department of Neurology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Chi Kyung Kim
- Department of Neurology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, South Korea.
| | - Sungwook Yu
- Department of Neurology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Kyungmi Oh
- Department of Neurology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Jong-Won Chung
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Gyeong-Moon Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jin-Man Jung
- Department of Neurology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, South Korea
| | - Tae-Jin Song
- Department of Neurology, Ewha Womans University, School of Medicine, Seoul, South Korea
| | - Yong-Jae Kim
- Department of Neurology, the Catholic University of Korea, Seoul, South Korea
| | - Bum Joon Kim
- Department of Neurology, Asan Medical Center, Seoul, South Korea
| | - Sung Hyuk Heo
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, South Korea
| | - Kwang-Yeol Park
- Department of Neurology, Chung-Ang University College of Medicine, Chung-Ang University Hospital, Seoul, South Korea
| | - Jeong-Min Kim
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Jong-Ho Park
- Department of Neurology, Myongji Hospital, Hanyang University College of medicine, Seoul, South Korea
| | - Jay Chol Choi
- Department of Neurology, Jeju National University, Jeju, South Korea
| | - Man-Seok Park
- Department of Neurology, Chonnam National University Hospital, Chonnam, South Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Chonnam, South Korea
| | - Kang-Ho Choi
- Department of Neurology, Chonnam National University Hospital, Chonnam, South Korea
| | - Yang Ha Hwang
- Department of Neurology, Kyungpook National University Hospital, Dae-gu, South Korea
| | - Woo-Keun Seo
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Departement of Digital Health, SHAIST, Sungkyunkwan University, Seoul, South Korea
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11
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Sánchez-González C, Herrero Calvo JA. Nonvalvular atrial fibrillation in patients undergoing chronic hemodialysis. Should dialysis patients with atrial fibrillation receive oral anticoagulation? Nefrologia 2022; 42:633-644. [PMID: 36907719 DOI: 10.1016/j.nefroe.2022.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 01/16/2022] [Indexed: 06/18/2023] Open
Abstract
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.
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Sarnak MJ, Auguste BL, Brown E, Chang AR, Chertow GM, Hannan M, Herzog CA, Nadeau-Fredette AC, Tang WHW, Wang AYM, Weiner DE, Chan CT. Cardiovascular Effects of Home Dialysis Therapies: A Scientific Statement From the American Heart Association. Circulation 2022; 146:e146-e164. [PMID: 35968722 DOI: 10.1161/cir.0000000000001088] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Cardiovascular disease is the leading cause of morbidity and mortality in patients with end-stage kidney disease. Currently, thrice-weekly in-center hemodialysis for 3 to 5 hours per session is the most common therapy worldwide for patients with treated kidney failure. Outcomes with thrice-weekly in-center hemodialysis are poor. Emerging evidence supports the overarching hypothesis that a more physiological approach to administering dialysis therapy, including in the home through home hemodialysis or peritoneal dialysis, may lead to improvement in several cardiovascular risk factors and cardiovascular outcomes compared with thrice-weekly in-center hemodialysis. The Advancing American Kidney Health Initiative, which has a goal of increasing the use of home dialysis, is aligned with the American Heart Association's 2024 mission to champion a full and healthy life and health equity. We conclude that incorporation of interdisciplinary care models to increase the use of home dialysis therapies in an equitable manner will contribute to the ultimate goal of improving outcomes for patients with kidney failure and cardiovascular disease.
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13
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Hachisuka M, Hayashi H, Iwasaki YK, Ito N, Arai T, Kobayashi S, Mimuro R, Fujimoto Y, Oka E, Hagiwara K, Tsuboi I, Murata H, Yamamoto T, Ogano M, Yodogawa K, Hayashi M, Shimizu W. Improvement in Quality of Life via Catheter Ablation for Atrial Fibrillation in Patients Undergoing Hemodialysis Therapy. CJC Open 2022; 4:748-755. [PMID: 36148254 PMCID: PMC9486863 DOI: 10.1016/j.cjco.2022.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 05/31/2022] [Indexed: 11/16/2022] Open
Abstract
Background Methods Results Conclusions
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Affiliation(s)
- Masato Hachisuka
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Hiroshi Hayashi
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
- Corresponding author: Dr Hiroshi Hayashi, Department of Cardiovascular Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan. Tel.: 81-3-3822-2131 x24007; fax: 81-3-5685-0987.
| | - Yu-ki Iwasaki
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Nobuaki Ito
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Toshiki Arai
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Serina Kobayashi
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Rei Mimuro
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Yuhi Fujimoto
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Eiichiro Oka
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Kanako Hagiwara
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Ippei Tsuboi
- Department of Cardiovascular Medicine, National Hospital Organization Shizuoka Medical Centre, Shizuoka, Japan
| | - Hiroshige Murata
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Teppei Yamamoto
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Michio Ogano
- Department of Cardiovascular Medicine, National Hospital Organization Shizuoka Medical Centre, Shizuoka, Japan
| | - Kenji Yodogawa
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Meiso Hayashi
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
- Mabori Medical Clinic, Yokosuka, Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
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Uchida T, Ookawara S, Ito K, Okada H, Hayasaka H, Kofuji M, Kimura M, Ueda Y, Hasebe T, Momose N, Morishita Y. Lethal ventricular arrhythmia can be prevented by adjusting the dialysate potassium concentration and the use of anti-arrhythmic agents: a case report and literature review. RENAL REPLACEMENT THERAPY 2022. [DOI: 10.1186/s41100-022-00410-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Hypokalemia is common in patients with malnutrition undergoing hemodialysis and is often involved in the development of lethal arrhythmia. Moreover, hemodialysis therapy decreases the serum potassium concentration due to potassium removal to the dialysate. However, it is difficult to adjust the dialysate potassium concentration owing to the use of the central dialysate delivery system in Japan. Here, we have presented a case undergoing hemodialysis with dialysate potassium concentration adjustment to prevent ventricular arrhythmia.
Case presentation
A 56-year-old man with Emery-Dreifuss muscular dystrophy and chronic heart failure was admitted to our hospital and needed subsequent hemodialysis therapy due to renal dysfunction. During hemodialysis, the cardiac resynchronization therapy defibrillator was activated to the treatment of his lethal ventricular arrhythmia. Decreases in serum potassium concentration after hemodialysis and changes in serum potassium concentration during HD were considered the causes of lethal ventricular arrythmia. Therefore, along with using anti-arrhythmic agents, the dialysate potassium concentration was increased from 2.0 to 3.5 mEq/L to minimize changes in the serum potassium concentration during hemodialysis. Post-dialysis hypokalemia disappeared and these changes during hemodialysis were minimized, and no lethal ventricular arrhythmia occurred thereafter.
Conclusions
In this case, we prevented lethal arrhythmia by maintaining the serum potassium concentration by increasing the dialysate potassium concentration, in addition to the use of anti-arrhythmic agents. In the acute phase of patients with frequent lethal arrhythmia undergoing hemodialysis, an increase in dialysate potassium concentration may be an effective method for preventing arrhythmogenic complications.
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15
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Ocak G, Khairoun M, Khairoun O, Bos WJW, Fu EL, Cramer MJ, Westerink J, Verhaar MC, Visseren FL. Chronic kidney disease and atrial fibrillation: A dangerous combination. PLoS One 2022; 17:e0266046. [PMID: 35390012 PMCID: PMC8989340 DOI: 10.1371/journal.pone.0266046] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 03/12/2022] [Indexed: 11/19/2022] Open
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.
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Affiliation(s)
- Gurbey Ocak
- Department of Internal Medicine, Sint Antonius Hospital, Nieuwegein, the Netherlands
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- * E-mail:
| | - Meriem Khairoun
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Othman Khairoun
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Willem Jan W. Bos
- Department of Internal Medicine, Sint Antonius Hospital, Nieuwegein, the Netherlands
- Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Edouard L. Fu
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Maarten J. Cramer
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jan Westerink
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marianne C. Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Frank L. Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
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Ras AB, Ghalwash D, Khalil E, Ahmed E. Assessment of serum and gingival crevicular fluid level of fibroblast growth factor 23 in patients having diseased periodontium with and without end-stage renal disease: A cross-sectional analytical study. J Int Oral Health 2022. [DOI: 10.4103/jioh.jioh_175_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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17
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Fibrilación auricular no valvular en pacientes en hemodiálisis crónica. ¿Debemos anticoagular? Nefrologia 2022. [DOI: 10.1016/j.nefro.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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18
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Braunisch MC, Mayer CC, Werfel S, Bauer A, Haller B, Lorenz G, Günthner R, Matschkal J, Bachmann Q, Thunich S, Schlegl M, Ludwig M, Holzmann-Littig C, Assali T, Pachmann M, Küchle C, Renders L, Wassertheurer S, Müller A, Schmidt G, Heemann U, Malik M, Schmaderer C. U-Shaped Association of the Heart Rate Variability Triangular Index and Mortality in Hemodialysis Patients With Atrial Fibrillation. Front Cardiovasc Med 2021; 8:751052. [PMID: 34912859 PMCID: PMC8667023 DOI: 10.3389/fcvm.2021.751052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 10/31/2021] [Indexed: 12/04/2022] Open
Abstract
Background: Atrial fibrillation (AF) is common in hemodialysis patients and contributes to increased mortality. We aimed to examine heart rate variability triangular index (HRVI) in hemodialysis patients with AF as it has recently been reported to predict mortality in AF patients without kidney disease. Methods: A total of 88 patients on hemodialysis with a medical history of AF or newly diagnosed AF underwent 24-h electrocardiography recordings. The primary endpoint of cardiovascular mortality was recorded during a median follow up of 3.0 years. Risk prediction was assessed by Cox regression, both unadjusted and adjusted for the Charlson Comorbidity Index and the Cardiovascular Mortality Risk Score. Results: Median age was 76 years, median dialysis vintage was 27 months. Altogether, 22 and 44 patients died due to cardiovascular and non-cardiovascular causes. In 55% of patients AF was present during the recording. Kaplan-Meier plots of HRVI quartiles suggested a non-linear association between HRVI, cardiovascular, and all-cause mortality which was confirmed in non-linear Cox regression analysis. Adjusted linear Cox regression revealed a hazard ratio of 6.2 (95% CI: 2.1-17.7, p = 0.001) and 2.2 (95% CI: 1.3-3.8, p = 0.002) for the outer quartiles (combined first and fourth quartile) for cardiovascular and all-cause mortality, respectively. Patients in the first quartile were more likely to have sinus rhythm whereas patients in the fourth quartile were more likely to have AF. Conclusions: We found a U-shaped association between HRVI and mortality in hemodialysis AF patients. The results might contribute to risk stratification independent of known risk scores in hemodialysis AF patients.
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Affiliation(s)
- Matthias C. Braunisch
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Christopher C. Mayer
- Center for Health and Bioresources, Biomedical Systems, AIT Austrian Institute of Technology GmbH, Vienna, Austria
| | - Stanislas Werfel
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Axel Bauer
- University Hospital for Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
- Department of Cardiology, Munich University Clinic, DZHK (German Centre for Cardiovascular Research), Ludwig-Maximilians University, Munich, Germany
| | - Bernhard Haller
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- School of Medicine, Klinikum Rechts der Isar, Institute of Medical Informatics, Statistics and Epidemiology (IMedIS), Technical University of Munich, Munich, Germany
| | - Georg Lorenz
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Roman Günthner
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Julia Matschkal
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Quirin Bachmann
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Stephan Thunich
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- School of Medicine, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Michaela Schlegl
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Maximilian Ludwig
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Christopher Holzmann-Littig
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Tarek Assali
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | | | - Claudius Küchle
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Lutz Renders
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Siegfried Wassertheurer
- Center for Health and Bioresources, Biomedical Systems, AIT Austrian Institute of Technology GmbH, Vienna, Austria
| | - Alexander Müller
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- School of Medicine, Klinik für Innere Medizin I, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Georg Schmidt
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- School of Medicine, Klinik für Innere Medizin I, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Uwe Heemann
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Marek Malik
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Department of Internal Medicine and Cardiology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Christoph Schmaderer
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
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Flythe JE, Liu S, Montez-Rath ME, Winkelmayer WC, Chang TI. Ultrafiltration rate and incident atrial fibrillation among older individuals initiating hemodialysis. Nephrol Dial Transplant 2021; 36:2084-2093. [PMID: 33561218 PMCID: PMC8826739 DOI: 10.1093/ndt/gfaa332] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Higher ultrafiltration (UF) rates are associated with numerous adverse cardiovascular outcomes among individuals receiving maintenance hemodialysis. We undertook this study to investigate the association of UF rate and incident atrial fibrillation in a large, nationally representative US cohort of incident, older hemodialysis patients. METHODS We used the US Renal Data System linked to the records of a large dialysis provider to identify individuals ≥67 years of age initiating hemodialysis between January 2006 and December 2011. We applied an extended Cox model as a function of a time-varying exposure to compute adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for the association of delivered UF rate and incident atrial fibrillation. RESULTS Among the 15 414 individuals included in the study, 3177 developed atrial fibrillation. In fully adjusted models, a UF rate >13 mL/h/kg (versus ≤13 mL/h/kg) was associated with a higher hazard of incident atrial fibrillation [adjusted HR 1.19 (95% CI 1.07-1.30)]. Analyses using lower UF rate thresholds (≤10 versus >10 mL/h/kg and ≤8 versus >8 mL/h/kg, separately) yielded similar results. Analyses specifying the UF rate as a cubic spline (per 1 mL/h/kg) confirmed an approximately linear dose-response relationship between the UF rate and the risk of incident atrial fibrillation: risk began at UF rates of ~6 mL/h/kg and the magnitude of this risk flattened, but remained elevated, at rates ≥9 mL/h/kg. CONCLUSION In this observational study of older individuals initiating hemodialysis, higher UF rates were associated with higher incidences of atrial fibrillation.
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Affiliation(s)
- Jennifer E Flythe
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina Kidney Center, University of North Carolina School of Medicine, Chapel Hill, NC, USA
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
| | - Sai Liu
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Maria E Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Wolfgang C Winkelmayer
- Section of Nephrology and Selzman Institute of Kidney Health, Baylor College of Medicine, Houston, TX, USA
| | - Tara I Chang
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, CA, USA
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20
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Hellman T, Uusalo P, Järvisalo MJ. New-onset atrial fibrillation in critically ill acute kidney injury patients on renal replacement therapy. Europace 2021; 24:211-217. [PMID: 34333634 PMCID: PMC8824521 DOI: 10.1093/europace/euab163] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/14/2021] [Indexed: 12/02/2022] Open
Abstract
Aims The effect of new-onset atrial fibrillation (NOAF) on mortality in critically ill patients with acute kidney injury (AKI) treated in the intensive care unit (ICU) requiring continuous veno-venous haemodialysis (CVVHD) or intermittent haemodialysis (IHD) is unknown. Thus, we examined the incidence of NOAF in critically ill AKI patients undergoing CVVHD or IHD and the association between the timing of NOAF incidence in relation to renal replacement therapy (RRT) initiation and 1-year mortality. Methods and results Out of the 733 consecutively recruited ICU patients requiring RRT within the study period of 2010–2019, 516 patients without prior atrial fibrillation history were included in this retrospective study. Clinical comorbidities, medications and biochemistry as well as outcome data for 1-year all-cause mortality were recorded. Episodes of NOAF were collected from the pooled rhythm data covering the entire ICU stay of every patient. The median age was 64 (inter-quartile range 19) years, 165 (32%) were female, and 356 and 160 patients received CVVHD and IHD, respectively. NOAF was observed in 190 (37%) patients during ICU care and 217 (42%) patients died within the 1-year follow-up. Incident NOAF was independently associated with 1-year mortality in the multivariable logistic regression analysis after adjusting for dialysis modality, need for mechanical ventilation or vasopressor support and Acute Physiology And Chronic Health Evaluation II score. However, NOAF diagnosed after RRT initiation was not associated with mortality. Conclusion NOAF emerging before RRT initiation is associated with increased mortality in critically ill AKI patients requiring RRT. However, NOAF during RRT does not seem to be associated with mortality.
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Affiliation(s)
- Tapio Hellman
- Kidney Center, Turku University Hospital and University of Turku, Hämeentie 11, PO Box 52, Turku 20521, Finland
| | - Panu Uusalo
- Department of Anaesthesiology and Intensive Care, Turku University Hospital and University of Turku, Hämeentie 11, PO Box 52, Turku 20521, Finland.,Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital and University of Turku, Hämeentie 11, PO Box 52, Turku 20521, Finland
| | - Mikko Johannes Järvisalo
- Kidney Center, Turku University Hospital and University of Turku, Hämeentie 11, PO Box 52, Turku 20521, Finland.,Department of Anaesthesiology and Intensive Care, Turku University Hospital and University of Turku, Hämeentie 11, PO Box 52, Turku 20521, Finland.,Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital and University of Turku, Hämeentie 11, PO Box 52, Turku 20521, Finland
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21
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Chang CH, Fan PC, Lin YS, Chen SW, Wu M, Lin MS, Lu CH, Chang PC, Hsieh MJ, Wang CY, Wang CL, Chu PH, Wu VCC. Dialysis Mode and Associated Outcomes in Patients With End-Stage Renal Disease and Atrial Fibrillation: A 14-Year Nationwide Cohort Study. J Am Heart Assoc 2021; 10:e019596. [PMID: 34075777 PMCID: PMC8477853 DOI: 10.1161/jaha.120.019596] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Benefits of patients with end-stage renal disease and atrial fibrillation undergoing peritoneal dialysis (PD) or hemodialysis are unknown. Methods and Results Patients undergoing dialysis were retrieved from Taiwan National Health Insurance Research Database during 2001 to 2013 and separated into PD or hemodialysis. Primary outcomes were ischemic stroke/systemic embolism, major bleeding, and intracranial hemorrhage (ICH). An inverse probability of treatment weighting based on propensity score was used to reduce the confounding. The risk of outcomes between PD and hemodialysis was compared using Cox proportional hazard model for fatal outcomes or Fine and Gray subdistribution hazard model which considered death a competing risk, respectively. A total of 7916 patients with end-stage renal disease with atrial fibrillation undergoing PD or hemodialysis during 2001 to 2013 were identified. After exclusion criteria, 363 patients receiving PD and 5302 patients receiving hemodialysis were analyzed. At 1-year follow-up, the risk of ICH was significantly lower in the PD group compared with the hemodialysis group (0.2% versus 0.9%; subdistribution hazard ratio [SHR], 0.31; 95% CI, 0.17-0.57). At 3-year follow-up, the risks of major bleeding and ICH were significantly lower in the PD group compared with the hemodialysis group (major bleeding: 1.8% versus 3.2%; SHR, 0.68; 95% CI, 0.53-0.87; ICH: 0.5% versus 2%; SHR, 0.32; 95% CI, 0.21-0.48). At 5-year follow-up, ischemic stroke/systemic embolism, major bleeding, and ICH were significantly lower in the PD group compared with the hemodialysis group (ischemic stroke/systemic embolism: 12.4% versus 17.7%, SHR, 0.87; 95% CI, 0.79-0.96; major bleeding: 2.6% versus 4.1%; SHR, 0.79; 95% CI, 0.64-0.97; ICH: 0.5% versus 2.6%; SHR, 0.25; 95% CI, 0.17-0.37). Conclusions In patients with end-stage renal disease and atrial fibrillation, dialytic modalities by PD or hemodialysis impacted these patients differently. There were overall reduced ischemic stroke/systemic embolism, major bleeding, and ICH at 5-year follow-up in patients undergoing PD compared with hemodialysis.
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Affiliation(s)
- Chih-Hsiang Chang
- Department of Nephrology Kidney Research CenterChang Gung Memorial HospitalLinkou Medical Center Taoyuan City Taiwan.,Graduate Institute of Clinical Medical Science College of Medicine Chang Gung University Taoyuan Taiwan
| | - Pei-Chun Fan
- Department of Nephrology Kidney Research CenterChang Gung Memorial HospitalLinkou Medical Center Taoyuan City Taiwan.,Graduate Institute of Clinical Medical Science College of Medicine Chang Gung University Taoyuan Taiwan
| | - Yu-Sheng Lin
- Department of Cardiology Chang Gung Memorial Hospital Chiayi Taiwan
| | - Shao-Wei Chen
- Department of Cardiothoracic and Vascular Surgery Chang Gung Memorial HospitalLinkou Medical Center Taoyuan City Taiwan
| | - Michael Wu
- Divison of Cardiovascular Medicine Arrhythmia Services SectionRhode Island HospitalWarren Alpert School of MedicineBrown University Providence RI
| | - Ming-Shyan Lin
- Department of Cardiology Chang Gung Memorial Hospital Chiayi Taiwan
| | - Cheng-Hui Lu
- Division of Cardiology Chang Gung Memorial HospitalLinkou Medical Center Taoyuan City Taiwan
| | - Po-Cheng Chang
- Division of Cardiology Chang Gung Memorial HospitalLinkou Medical Center Taoyuan City Taiwan
| | - Ming-Jer Hsieh
- Division of Cardiology Chang Gung Memorial HospitalLinkou Medical Center Taoyuan City Taiwan
| | - Chao-Yung Wang
- Division of Cardiology Chang Gung Memorial HospitalLinkou Medical Center Taoyuan City Taiwan
| | - Chun-Li Wang
- Division of Cardiology Chang Gung Memorial HospitalLinkou Medical Center Taoyuan City Taiwan
| | - Pao-Hsien Chu
- Division of Cardiology Chang Gung Memorial HospitalLinkou Medical Center Taoyuan City Taiwan
| | - Victor Chien-Chia Wu
- Division of Cardiology Chang Gung Memorial HospitalLinkou Medical Center Taoyuan City Taiwan
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22
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Clerx M, Mirams GR, Rogers AJ, Narayan SM, Giles WR. Immediate and Delayed Response of Simulated Human Atrial Myocytes to Clinically-Relevant Hypokalemia. Front Physiol 2021; 12:651162. [PMID: 34122128 PMCID: PMC8188899 DOI: 10.3389/fphys.2021.651162] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/22/2021] [Indexed: 12/18/2022] Open
Abstract
Although plasma electrolyte levels are quickly and precisely regulated in the mammalian cardiovascular system, even small transient changes in K+, Na+, Ca2+, and/or Mg2+ can significantly alter physiological responses in the heart, blood vessels, and intrinsic (intracardiac) autonomic nervous system. We have used mathematical models of the human atrial action potential (AP) to explore the electrophysiological mechanisms that underlie changes in resting potential (Vr) and the AP following decreases in plasma K+, [K+]o, that were selected to mimic clinical hypokalemia. Such changes may be associated with arrhythmias and are commonly encountered in patients (i) in therapy for hypertension and heart failure; (ii) undergoing renal dialysis; (iii) with any disease with acid-base imbalance; or (iv) post-operatively. Our study emphasizes clinically-relevant hypokalemic conditions, corresponding to [K+]o reductions of approximately 1.5 mM from the normal value of 4 to 4.5 mM. We show how the resulting electrophysiological responses in human atrial myocytes progress within two distinct time frames: (i) Immediately after [K+]o is reduced, the K+-sensing mechanism of the background inward rectifier current (IK1) responds. Specifically, its highly non-linear current-voltage relationship changes significantly as judged by the voltage dependence of its region of outward current. This rapidly alters, and sometimes even depolarizes, Vr and can also markedly prolong the final repolarization phase of the AP, thus modulating excitability and refractoriness. (ii) A second much slower electrophysiological response (developing 5-10 minutes after [K+]o is reduced) results from alterations in the intracellular electrolyte balance. A progressive shift in intracellular [Na+]i causes a change in the outward electrogenic current generated by the Na+/K+ pump, thereby modifying Vr and AP repolarization and changing the human atrial electrophysiological substrate. In this study, these two effects were investigated quantitatively, using seven published models of the human atrial AP. This highlighted the important role of IK1 rectification when analyzing both the mechanisms by which [K+]o regulates Vr and how the AP waveform may contribute to "trigger" mechanisms within the proarrhythmic substrate. Our simulations complement and extend previous studies aimed at understanding key factors by which decreases in [K+]o can produce effects that are known to promote atrial arrhythmias in human hearts.
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Affiliation(s)
- Michael Clerx
- Centre for Mathematical Medicine and Biology, School of Mathematical Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Gary R Mirams
- Centre for Mathematical Medicine and Biology, School of Mathematical Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Albert J Rogers
- Department of Medicine and Cardiovascular Institute, Stanford University, Stanford, CA, United States
| | - Sanjiv M Narayan
- Department of Medicine and Cardiovascular Institute, Stanford University, Stanford, CA, United States
| | - Wayne R Giles
- Department of Physiology and Pharmacology, University of Calgary, Calgary, AB, Canada
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23
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Bel-Ange A, Itskovich SZ, Avivi L, Stav K, Efrati S, Beberashvili I. Prior ischemic strokes are non-inferior for predicting future ischemic strokes than CHA 2DS 2-VASc score in hemodialysis patients with non-valvular atrial fibrillation. BMC Nephrol 2021; 22:179. [PMID: 33992086 PMCID: PMC8126112 DOI: 10.1186/s12882-021-02384-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/20/2021] [Indexed: 11/23/2022] Open
Abstract
Background We tested whether CHA2DS2-VASc and/or HAS-BLED scores better predict ischemic stroke and major bleeding, respectively, than their individual components in maintenance hemodialysis (MHD) patients with atrial fibrillation (AF). Methods A retrospective cohort study of a clinical database containing the medical records of 268 MHD patients with non-valvular AF (167 women, mean age 73.4 ± 10.2 years). During the median follow-up of 21.0 (interquartile range, 5.0–44.0) months, 46 (17.2%) ischemic strokes and 24 (9.0%) major bleeding events were reported. Results Although CHA2DS2-VASc predicted ischemic stroke risk in the study population (adjusted HR 1.74 with 95% CI 1.23–2.46 for each unit of increase in CHA2DS2-VASc score, and HR of 5.57 with 95% CI 1.88–16.49 for CHA2DS2-VASc score ≥ 6), prior ischemic strokes/transient ischemic attacks (TIAs) were non-inferior in both univariate and multivariate analyses (adjusted HR 8.65 with 95% CI 2.82–26.49). The ROC AUC was larger for the prior ischemic stroke/TIA than for CHA2DS2-VASc. Furthermore, the CHA2DS2-VASc score did not predict future ischemic stroke risks in study participants who did not previously experience ischemic strokes/TIAs (adjusted HR 1.41, 95% CI: 0.84–2.36). The HAS-BLED score and its components did not have predictive abilities in discriminating bleeding risk in the study population. Conclusions Previous ischemic strokes are non-inferior for predicting of future ischemic strokes than the complete CHA2DS2-VASc score in MHD patients. CHA2DS2VASc scores are less predictive in MHD patients without histories of CVA/TIA. HAS-BLED scores do not predict major bleeding in MHD patients. These findings should redesign approaches to ischemic stroke risk stratification in MHD patients if future large-scale epidemiological studies confirm them.
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Affiliation(s)
- Anat Bel-Ange
- Internal Department C, affiliated with the Sackler Faculty of Medicine, Yitzhak Shamir Medical Center, Tel Aviv University, Zerifin, Israel
| | - Shani Zilberman Itskovich
- Nephrology Division, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Yitzhak Shamir Medical Center, 70300, Zerifin, Israel
| | - Liana Avivi
- Internal Department D, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Yitzhak Shamir Medical Center, Zerifin, Israel
| | - Kobi Stav
- Urology Department, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Yitzhak Shamir Medical Center, Zerifin, Israel
| | - Shai Efrati
- Nephrology Division, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Yitzhak Shamir Medical Center, 70300, Zerifin, Israel
| | - Ilia Beberashvili
- Nephrology Division, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Yitzhak Shamir Medical Center, 70300, Zerifin, Israel.
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24
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De Vriese AS, Heine G. Anticoagulation Management In Hemodialysis Patients With Atrial Fibrillation: Evidence And Opinion. Nephrol Dial Transplant 2021; 37:2072-2079. [PMID: 33647941 DOI: 10.1093/ndt/gfab060] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Indexed: 01/09/2023] Open
Abstract
In the absence of robust evidence to guide clinical decision making, the optimal approach to prevent stroke and systemic embolism in hemodialysis patients with atrial fibrillation (AF) remains moot. In this position paper, studies on oral anticoagulation in hemodialysis patients with AF are highlighted, followed by an evidence-based conclusion, a critical analysis to identify sources of bias, and practical opinion-based suggestions on how to manage anticoagulation in this specific population. It remains unclear whether AF is a true risk factor for embolic stroke in hemodialysis. The currently employed cutoff values for the CHA2DS2-VASc score do not adequately discriminate dialysis patients deriving a net benefit from those suffering a net harm from oral anticoagulation. Anticoagulation initiation should probably be more restrictive than currently advocated by official guidelines. Recent evidence reveals that the superior benefit-risk profile of direct oral anticoagulants (DOAC) versus vitamin K antagonists (VKA) observed in the general population and in moderate chronic kidney disease can be extended to the hemodialysis population. VKA may be especially harmful in dialysis patients and should therefore be avoided, in particular in patients with a high bleeding risk and labile international normalized ratio. Dose-finding studies of DOAC suggest that rivaroxaban 10 mg daily and apixaban 2.5 mg twice daily are appropriate choices in dialysis patients. Combined treatment of oral anticoagulants and antiplatelet agents should be reserved for strong indications and limited in time. Left atrial appendage occlusion is a potential attractive solution to reduce the risk of stroke without increasing bleeding propensity, but has not been properly studied in dialysis patients.
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Affiliation(s)
- An S De Vriese
- Division of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge, Brugge, and Ghent University, Ghent, Belgium
| | - Gunnar Heine
- AGAPLESION MARKUS KRANKENHAUS, Frankfurt, and Saarland University Faculty of Medicine, Homburg, Germany
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25
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Kang Y, Choi HY, Kwon YE, Shin JH, Won EM, Yang KH, Oh HJ, Ryu DR. Clinical outcomes among hemodialysis patients with atrial fibrillation: a Korean nationwide population-based study. Kidney Res Clin Pract 2021; 40:99-108. [PMID: 33789385 PMCID: PMC8041641 DOI: 10.23876/j.krcp.20.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 09/10/2020] [Indexed: 12/01/2022] Open
Abstract
Background The number of patients requiring dialysis is increasing worldwide, and the atrial fibrillation and atrial flutter (AF) prevalence among hemodialysis (HD) patients is higher than in the general population. There have been no studies of Korean AF patients undergoing HD that investigated how AF affects outcomes, such as all-cause mortality, hospitalization, and stroke events. We conducted a large-scale retrospective cohort study with data from the National Health Insurance System to determine how AF affects these outcomes. Methods In 2013, the Health Insurance Review and Assessment service, a Korean national health insurance scheme, collected data from 21,839 HD patients to evaluate the adequacy of dialysis centers. All-cause mortality, hospitalization, and stroke events were compared between patients with and without AF. Sub-analyses compared these outcomes between AF patients receiving warfarin and those not receiving warfarin. Results Cox regression analysis found that AF was a significant risk factor for death from any cause (hazard ratio [HR], 1.356; 95% confidence interval [CI], 1.222–1.506; p < 0.001), hospitalization (HR, 1.323; 95% CI, 1.225–1.430; p < 0.001), and hemorrhagic stroke (HR, 1.500; 95% CI, 1.050–2.141; p = 0.026). AF was not significantly associated with an increased risk of ischemic stroke. The use of warfarin was significantly associated with hemorrhagic stroke incidence (HR, 1.593; 95% CI, 1.075–2.360; p = 0.020), while there was no significant correlation between warfarin treatment and all-cause mortality, hospitalization, and ischemic stroke. Conclusion This cohort study of Korean dialysis patients showed that AF was a risk factor for multiple outcomes among HD patients.
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Affiliation(s)
- Yeunmi Kang
- Department of Internal Medicine, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
| | - Hyung Yun Choi
- The Korean Society of Nephrology, Seoul, Republic of Korea
| | - Young Eun Kwon
- Department of Internal Medicine, Myongji Hospital, Hanyang University College of Medicine, Goyang, Republic of Korea
| | - Ji Hyeon Shin
- Health Insurance Review and Assessment Service, Wonju, Republic of Korea
| | - Eun Mi Won
- Health Insurance Review and Assessment Service, Wonju, Republic of Korea
| | - Ki Hwa Yang
- Health Insurance Review and Assessment Service, Wonju, Republic of Korea
| | - Hyung Jung Oh
- Ewha Institute of Convergence Medicine, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea.,Research Institute for Human Health Information, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
| | - Dong-Ryeol Ryu
- Research Institute for Human Health Information, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Republic of Korea
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26
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Shawwa K, Kompotiatis P, Bobart SA, Mara KC, Wiley BM, Jentzer JC, Kashani KB. New-onset atrial fibrillation in patients with acute kidney injury on continuous renal replacement therapy. J Crit Care 2020; 62:157-163. [PMID: 33383309 DOI: 10.1016/j.jcrc.2020.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/21/2020] [Accepted: 12/11/2020] [Indexed: 02/09/2023]
Abstract
PURPOSE The mortality of critically ill patients with acute kidney injury (AKI) who require continuous renal replacement therapy (CRRT) remains high. We assessed the incidence and predictors of new-onset atrial fibrillation (NOAF) in this population and its impact on outcomes. MATERIALS AND METHODS This is a retrospective cohort study of adult intensive care units (ICU) patients who had AKI and received CRRT from December 2006 through November 2015 in a tertiary academic medical center. Cox proportional hazard model was used to evaluate the impact of NOAF on overall mortality. RESULTS Out of 1398 screened patients, NOAF occurred in 193 (14%) cases. NOAF occurring on CRRT was independently associated with an increased hazard of death at follow-up (HR: 1.26; 95% CI: 1.03-1.56), compared to the group who did not have NOAF. In the multivariable analysis using time-dependent covariates, higher potassium (HR 1.24, 95%CI: 1.01-1.54) and bicarbonate (HR 0.95, 95%CI: 0.92-0.98) levels were associated with increased and decreased risk of NOAF on CRRT, respectively. CONCLUSIONS NOAF in critically ill patients with AKI receiving CRRT is common and carries an unfavorable prognosis. Prospective studies are required to elucidate modifiable risk factors for NOAF occurring on CRRT.
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Affiliation(s)
- Khaled Shawwa
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Panagiotis Kompotiatis
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Shane A Bobart
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kristin C Mara
- Department of Health Science Research, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Brandon M Wiley
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
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27
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Hakamäki M, Hellman T, Lankinen R, Koivuviita N, Pärkkä J, Kallio P, Kiviniemi T, Airaksinen KEJ, Järvisalo MJ, Metsärinne K. Elevated Troponin T and Enlarged Left Atrium Are Associated with the Incidence of Atrial Fibrillation in Patients with CKD Stage 4-5. Nephron Clin Pract 2020; 145:71-77. [PMID: 33264772 DOI: 10.1159/000511451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 09/08/2020] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Markus Hakamäki
- Kidney Center, Turku University Hospital and University of Turku, Turku, Finland,
| | - Tapio Hellman
- Kidney Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Roosa Lankinen
- Kidney Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Niina Koivuviita
- Kidney Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Jussi Pärkkä
- Department of Clinical Physiology, Turku University Hospital and University of Turku, Turku, Finland
| | - Petri Kallio
- Department of Clinical Physiology, Turku University Hospital and University of Turku, Turku, Finland.,Paavo Nurmi Centre & Unit for Health and Physical Activity, University of Turku, Turku, Finland
| | - Tuomas Kiviniemi
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Mikko J Järvisalo
- Kidney Center, Turku University Hospital and University of Turku, Turku, Finland.,Department of Anaesthesiology and Intensive Care, Turku University Hospital and University of Turku, Turku, Finland.,Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Kaj Metsärinne
- Kidney Center, Turku University Hospital and University of Turku, Turku, Finland
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28
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Goel N, Jain D, Haddad DB, Shanbhogue D. Anticoagulation in Patients with End-Stage Renal Disease and Atrial Fibrillation: Confusion, Concerns and Consequences. J Stroke 2020; 22:306-316. [PMID: 33053946 PMCID: PMC7568986 DOI: 10.5853/jos.2020.01886] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 07/22/2020] [Accepted: 07/27/2020] [Indexed: 12/28/2022] Open
Abstract
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.
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Affiliation(s)
- Narender Goel
- New Jersey Kidney Care, Jersey, NJ, USA
- Division of Nephrology, CarePoint Health Hospitals, Jersey, NJ, USA
- Division of Nephrology, Jersey City Medical Center, Jersey, NJ, USA
| | - Deepika Jain
- New Jersey Kidney Care, Jersey, NJ, USA
- Division of Nephrology, CarePoint Health Hospitals, Jersey, NJ, USA
- Division of Nephrology, Jersey City Medical Center, Jersey, NJ, USA
| | - Danny B. Haddad
- New Jersey Kidney Care, Jersey, NJ, USA
- Division of Nephrology, CarePoint Health Hospitals, Jersey, NJ, USA
- Division of Nephrology, Jersey City Medical Center, Jersey, NJ, USA
| | - Divya Shanbhogue
- Department of Medicine, Jersey City Medical Center, Jersey, NJ, USA
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29
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de Jong Y, Ramspek CL, van der Endt VHW, Rookmaaker MB, Blankestijn PJ, Vernooij RWM, Verhaar MC, Bos WJW, Dekker FW, Ocak G, van Diepen M. A systematic review and external validation of stroke prediction models demonstrates poor performance in dialysis patients. J Clin Epidemiol 2020; 123:69-79. [PMID: 32240769 DOI: 10.1016/j.jclinepi.2020.03.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 02/20/2020] [Accepted: 03/19/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVES The objective of this study was to systematically review and externally assess the predictive performance of models for ischemic stroke in incident dialysis patients. STUDY DESIGN AND SETTING Two reviewers systematically searched and selected ischemic stroke models. Risk of bias was assessed with the PROBAST. Predictive performance was evaluated within The Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD), a large prospective multicenter cohort of incident dialysis patients. For discrimination, c-statistics were calculated; calibration was assessed by plotting predicted and observed probabilities for stroke, and calibration-in-the-large. RESULTS Seventy-seven prediction models for stroke were identified, of which 15 were validated. Risk of bias was high, with all of these models scoring high risk in one or more domains. In NECOSAD, of the 1,955 patients, 127 (6.5%) suffered an ischemic stroke during the follow-up of 2.5 years. Compared with the original studies, most models performed worse with all models showing poor calibration and discriminative abilities (c-statistics ranging from 0.49 to 0.66). The Framingham showed reasonable calibration; however, with a c-statistic of 0.57 (95% CI 0.50-0.63), the discrimination was poor. CONCLUSION This external validation demonstrates the weak predictive performance of ischemic stroke models in incident dialysis patients. Instead of using these models in this fragile population, either existing models should be updated, or novel models should be developed and validated.
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Affiliation(s)
- Ype de Jong
- Department of Clinical Epidemiology, Leiden University Medical Center (LUMC), Leiden, The Netherlands; Department of Internal Medicine, Leiden University Medical Center (LUMC), Leiden, The Netherlands.
| | - Chava L Ramspek
- Department of Clinical Epidemiology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Vera H W van der Endt
- Department of Clinical Epidemiology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Maarten B Rookmaaker
- Department of Nephrology and Hypertension, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Peter J Blankestijn
- Department of Nephrology and Hypertension, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Robin W M Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marianne C Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Willem Jan W Bos
- Department of Internal Medicine, Leiden University Medical Center (LUMC), Leiden, The Netherlands; Department of Internal Medicine, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Gurbey Ocak
- Department of Nephrology and Hypertension, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Merel van Diepen
- Department of Clinical Epidemiology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
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Abstract
Patients with chronic kidney disease (CKD) are at increased risk for kidney failure, cardiovascular disease (CVD), and death. In fact, the likelihood of dying from CVD is markedly higher than that for reaching end-stage renal disease. Evidence-based management of comorbidities such as CVD remains challenging in patients with advanced CKD, as they were usually excluded from randomized controlled trials. This review focuses on the epidemiology, risk factors, and clinical manifestations of CVD in patients with advanced CKD. Specific topics of interest include diagnostic and therapeutic challenges of heart failure, coronary artery disease, and atrial fibrillation.
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Affiliation(s)
- Turgay Saritas
- Nephrology and Clinical Immunology, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - Jürgen Floege
- Nephrology and Clinical Immunology, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
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Cryoballoon versus radiofrequency ablation for paroxysmal atrial fibrillation in hemodialysis patients. Heart Vessels 2020; 35:1709-1716. [PMID: 32524235 DOI: 10.1007/s00380-020-01646-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 06/05/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Little evidence exists regarding cryoballoon ablation (CBA) of paroxysmal atrial fibrillation (PAF) in hemodialysis (HD) patients. We compared CBA and radiofrequency ablation (RFA) of PAF in HD patients, referring to CBA of PAF in non-HD patients. METHODS AND RESULTS This historical cohort study examined 88 patients who underwent catheter ablation of PAF, including 21 HD patients with a second-generation 28-mm cryoballoon (CB-HD group), 17 HD patients with a non-force-sensing radiofrequency catheter (RF-HD group), and 50 non-HD patients with a cryoballoon (CB-non-HD group). Pulmonary vein (PV) isolation alone aside from cavotricuspid isthmus ablation was performed in 14 (67%) in the CB-HD group, 12 (71%) in the RF-HD group, and 36 (72%) in the CB-non-HD group (P = 0.95), without isoproterenol-induced non-PV triggers. Non-PV trigger ablation was added to the other patients. The Kaplan-Meier estimated 1-year freedom from atrial tachyarrhythmia recurrence without antiarrhythmic drugs after a single procedure was 76%, 59%, and, 92% in the CB-HD, RF-HD, and CB-non-HD groups, respectively (P = 0.002). The mean procedure time was shorter in the CB-HD group than in the RF-HD group (127 vs. 199 min; P < 0.001). In the second procedure, the median number of reconnected pulmonary veins was 0.5 in the CB-HD group versus 2.0 in the RF-HD group (P = 0.17). CONCLUSION For PAF in HD patients, CBA showed a comparable single-procedure efficacy to that of RFA with a short procedure time. CBA may be a reasonable initial procedure for HD patients suffering from symptomatic PAF.
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AlAwwa I, Al-Hindi R, Alfraihat N, Obeid A, Ibrahim S, Jallad S, Al-Awwa A, Saleh A. Prevalence and associated factors of undiagnosed atrial fibrillation among end-stage renal disease patients on maintenance haemodialysis: a cross-sectional study. BMC Cardiovasc Disord 2020; 20:186. [PMID: 32316914 PMCID: PMC7175504 DOI: 10.1186/s12872-020-01473-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 04/07/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is the most prevalent sustained arrhythmia worldwide and it aggravates cardiovascular morbidity and mortality; however, this is largely under-diagnosed. Moreover, among end-stage renal disease patients on haemodialysis, AF is substantially more common and serious. The researchers conducted this study to assess the prevalence of, and the factors correlated with AF in Jordanian haemodialysis patients. METHODS In a cross-sectional analysis conducted from October 2018 to February 2019 in four tertiary hospitals, the researchers enrolled all consenting patients aged 18 years or older who were on haemodialysis for at least three months prior to the study. We screened for AF clinically by pulse palpation, precordial auscultation, by an automated blood pressure monitor and an electrocardiogram. The researchers reported qualitative variables as counts and frequencies, while continuous variables were summarised using the mean or median where necessary. We used multiple logistic regression with backward selection to identify independent risk factors of AF. RESULTS A total of 231 patients were enrolled; mean age was 54.8 ± 15.6 years (from 20 to 86), and 44.3% of them were women. The prevalence of AF was found to be 7.8% (95% CI, 4.8-12.2), with no gender disparity. Age (adjusted odds ratio [AOR] = 1.05; 95% CI, 1.01-1.10; p = 0.031), history of ischaemic heart disease (AOR = 3.74; 95% CI, 1.09-12.34; p = 0.033), history of smoking (AOR = 0.15; 95% CI, 0.02-0.60; p = 0.019), and low interdialytic weight gain (AOR = 0.50: 95% CI, 0.25-0.91; p = 0.031) were independently correlated to AF. CONCLUSIONS The prevalence of AF among patients on maintenance haemodialysis is high, but largely undiagnosed. AF is generally associated with advancing age, history of ischaemic heart disease, lower interdialytic weight gain, and history of smoking. We suggest routine check-up of AF in this high-risk group of patients as anticoagulant therapy if indicated may prevent serious complications. However, there is a need for large-scale cohort studies and for the creation of regional chronic kidney disease and dialysis registries in the Middle East region.
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Affiliation(s)
- Izzat AlAwwa
- School of medicine, the University of Jordan, PO Box 954180, Amman, 11954 Jordan
| | | | | | | | | | | | | | - Akram Saleh
- School of medicine, the University of Jordan, PO Box 954180, Amman, 11954 Jordan
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Ocak G, Ramspek C, Rookmaaker MB, Blankestijn PJ, Verhaar MC, Bos WJW, Dekker FW, van Diepen M. Performance of bleeding risk scores in dialysis patients. Nephrol Dial Transplant 2020; 34:1223-1231. [PMID: 30608543 DOI: 10.1093/ndt/gfy387] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Bleeding risk scores have been created to identify patients with an increased bleeding risk, which could also be useful in dialysis patients. However, the predictive performances of these bleeding risk scores in dialysis patients are unknown. Therefore, the aim of this study was to validate existing bleeding risk scores in dialysis patients. METHODS A cohort of 1745 incident dialysis patients was prospectively followed for 3 years during which bleeding events were registered. We evaluated the discriminative performance of the Hypertension, Abnormal kidney and liver function, Stroke, Bleeding, Labile INR, Elderly and Drugs or alcohol (HASBLED), the AnTicoagulation and Risk factors In Atrial fibrillation (ATRIA), the Hepatic or kidney disease, Ethanol abuse, Malignancy, Older age, Reduced platelet count or Reduced platelet function, Hypertension, Anaemia, Genetic factors, Excessive fall risk and Stroke (HEMORR2HAGES) and the Outcomes Registry for Better Informed Treatment (ORBIT) bleeding risk scores by calculating C-statistics with 95% confidence intervals (CI). In addition, calibration was evaluated by comparing predicted and observed risks. RESULTS Of the 1745 dialysis patients, 183 patients had a bleeding event, corresponding to an incidence rate of 5.23/100 person-years. The HASBLED [C-statistic of 0.58 (95% CI 0.54-0.62)], ATRIA [C-statistic of 0.55 (95% CI 0.51-0.60)], HEMORR2HAGES [C-statistic of 0.56 (95% CI 0.52-0.61)] and ORBIT [C-statistic of 0.56 (95% CI 0.52-0.61)] risk scores had poor discriminative performances in dialysis patients. Furthermore, the calibration analyses showed that patients with a low risk of bleeding according to the HASBLED, ATRIA, HEMORR2HAGES and ORBIT bleeding risk scores had higher incidence rates for bleeding in our cohort than predicted. CONCLUSIONS The HASBLED, ATRIA, HEMORR2HAGES and ORBIT bleeding risk scores had poor predictive abilities in dialysis patients. Therefore, these bleeding risk scores may not be useful in this population.
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Affiliation(s)
- Gurbey Ocak
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Chava Ramspek
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Maarten B Rookmaaker
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Peter J Blankestijn
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marianne C Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Willem Jan W Bos
- Department of Internal Medicine, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Merel van Diepen
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
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Chang CH, Fan PC, Lin YS, Chen SW, Lin MS, Wu M, Chang PC, Lin FC, Chu PH, Wu VCC. Atrial fibrillation and associated outcomes in patients with peritoneal dialysis and hemodialysis: a 14-year nationwide population-based study. J Nephrol 2020; 34:53-62. [PMID: 32086785 DOI: 10.1007/s40620-020-00713-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 02/15/2020] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Chih-Hsiang Chang
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan.,Graduate Institute of Clinical Medical Science, College of Medicine, Chang Gung University, Taoyuan City, 333, Taiwan
| | - Pei-Chun Fan
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan.,Graduate Institute of Clinical Medical Science, College of Medicine, Chang Gung University, Taoyuan City, 333, Taiwan
| | - Yu-Sheng Lin
- Department of Cardiology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Shao-Wei Chen
- Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan
| | - Ming-Shyan Lin
- Department of Cardiology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Michael Wu
- Divison of Cardiovascular Medicine, Arrhythmia Services Section, Rhode Island Hospital, Warren Alpert School of Medicine, Brown University, Providence, USA
| | - Po-Cheng Chang
- Division of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, No. 5, Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan
| | - Fen-Chiung Lin
- Division of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, No. 5, Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan
| | - Pao-Hsien Chu
- Division of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, No. 5, Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan
| | - Victor Chien-Chia Wu
- Division of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, No. 5, Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan.
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Baek SD, Jeung S, Kang JY, Jeon KH. Dialysis-specific factors and incident atrial fibrillation in hemodialysis patients. Ren Fail 2020; 42:785-791. [PMID: 32779958 PMCID: PMC7472506 DOI: 10.1080/0886022x.2020.1801467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Atrial fibrillation (AF) is common in end-stage renal disease patients. Besides the traditional risk factors, we aimed to find dialysis-specific factors for developing incident AF. Methods From March 2017 to August 2018, we retrospectively reviewed all outpatient-based prevalent hemodialysis patients in our artificial kidney room, and they were followed up until August 2019. Dialysate calcium concentration (3 versus 2.5 mEq/L), time length (4 versus 3.5 h), frequency (thrice weekly versus twice weekly), dialyzer size (effective surface area of 1.4 m2 versus 1.8 m2), membrane permeability (high flux versus low flux), ultrafiltration rate (mL/kg/hour), and blood flow rate (mL/min) were evaluated. Results Among a total of 84 patients, 15 (17.9%) had newly detected AF with a follow-up period of 21 (13.3–24) months. By performing multivariate Cox regression analysis, blood flow rate (mL/min) and ultrafiltration rate (mL/kg/h) were considered significant factors for developing incident AF (adjusted hazard ratio [HR], 0.977; p = 0.011 and adjusted HR, 1.176; p = 0.013, respectively), while dialysis bath, time length, and frequency, dialyzer size, and membrane type were not considered significant factors. Ultrafiltration cutoff rate of 8.6 mL/kg/h was the best predictive factor for incident AF (area under the curve-receiver operating characteristic [AUC-ROC], 0.746; p < 0.005), while blood flow rate was not considered a significant factor for incident AF in ROC analysis (AUC-ROC, 0.623; p = 0.126). Ultrafiltration rate was largely dependent on interdialytic weight gain (p < 0.005, linear-by-linear association). Conclusion Higher ultrafiltration rate was associated with incident AF in hemodialysis patients.
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Affiliation(s)
- Seung Don Baek
- Department of Internal Medicine, Division of Nephrology, Mediplex Sejong Hospital, Incheon, Korea
| | - Soomin Jeung
- Department of Internal Medicine, Division of Nephrology, Mediplex Sejong Hospital, Incheon, Korea
| | - Jae-Young Kang
- Department of Internal Medicine, Division of Nephrology, Sejong General Hospital, Bucheon, Korea
| | - Ki Hyun Jeon
- Department of Internal Medicine, Division of Cardiology, Mediplex Sejong Hospital, Incheon, Korea
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Königsbrügge O, Ay C. Atrial fibrillation in patients with end-stage renal disease on hemodialysis: Magnitude of the problem and new approach to oral anticoagulation. Res Pract Thromb Haemost 2019; 3:578-588. [PMID: 31624777 PMCID: PMC6781927 DOI: 10.1002/rth2.12250] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 07/19/2019] [Accepted: 07/22/2019] [Indexed: 01/04/2023] Open
Abstract
Atrial fibrillation (AF) is a frequent comorbid condition in patients with end-stage renal disease on hemodialysis (HD) with a prevalence of up to 27%. The incidence rate of stroke in AF patients on HD is approximately 5%. The AF-associated risk of stroke is a major clinical challenge because current evidence for anticoagulation in HD patients with AF is based on observational data. Results from these observational studies is largely contradictory because they do not show a clear benefit of vitamin K antagonists over no treatment in terms of stroke prevention, and they show an increased risk of hemorrhage associated with anticoagulation treatment in HD patients. HD patients were not included in randomized trials of the direct oral anticoagulants (DOACs), and therefore there is no evidence to support efficacy and safety of DOACs compared to vitamin K antagonists in HD patients. The pharmacological characteristics of DOACs are of particular interest in the HD setting. The factor Xa inhibitors rivaroxaban, apixaban, and edoxaban are not predominantly eliminated via the kidneys. The thrombin inhibitor dabigatran is 80% eliminated via the kidneys but is dialyzable due to its low protein binding. In this narrative review, we examine the current state of evidence regarding the prevalence of AF in patients on HD, the associated risk of stroke, and the efficacy and safety of anticoagulation for stroke prevention in the HD setting. Further, based on the pharmacokinetic properties of DOACs, we discuss their potential use in patients on HD and ongoing randomized trials.
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Affiliation(s)
- Oliver Königsbrügge
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Cihan Ay
- Clinical Division of Hematology and HemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
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Rantanen JM, Riahi S, Schmidt EB, Johansen MB, Søgaard P, Christensen JH. Arrhythmias in Patients on Maintenance Dialysis: A Cross-sectional Study. Am J Kidney Dis 2019; 75:214-224. [PMID: 31542235 DOI: 10.1053/j.ajkd.2019.06.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 06/29/2019] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Patients with kidney failure treated with maintenance dialysis experience a high rate of mortality, in part due to sudden cardiac death caused by arrhythmias. The prevalence of arrhythmias, including the subset that are clinically significant, is not well known. This study sought to estimate the prevalence of arrhythmias, characterize the pattern of arrhythmic events in relation to dialysis treatments, and identify associated clinical characteristics. STUDY DESIGN Cross-sectional study. SETTING & PARTICIPANTS 152 patients with kidney failure treated with maintenance dialysis in Denmark. EXPOSURES Dialysis treatment; clinical characteristics; cardiac output and preload defined using echocardiography. OUTCOMES Prevalence and pattern of arrhythmias on 48-hour Holter monitoring; odds ratios for arrhythmias. ANALYTICAL APPROACH Descriptive analysis of the prevalence of arrhythmias. Pattern of arrhythmias described using a repeated-measures negative binomial regression model. Associations between clinical characteristics and echocardiographic findings with arrhythmias were assessed using logistic regression. RESULTS Among the 152 patients studied, 83.6% were treated with in-center dialysis; 10.5%, with home hemodialysis; and 5.9%, with peritoneal dialysis. Premature atrial and ventricular complexes were seen in nearly all patients and 41% had paroxysmal supraventricular tachycardia. Clinically significant arrhythmias included persistent atrial fibrillation observed among 8.6% of patients, paroxysmal atrial fibrillation among 3.9%, nonsustained ventricular tachycardia among 19.7%, bradycardia among 4.6%, advanced second-degree atrioventricular block among 1.3%, and third-degree atrioventricular block among 2.6%. Premature ventricular complexes were more common on dialysis days, while tachyarrhythmias were more often observed during dialysis and in the immediate postdialytic period. Older age (OR per 10 years older, 1.53; 95% CI, 1.15-2.03; P=0.003), elevated preload (OR, 4.02; 95% CI, 1.05-15.35; P=0.04), and lower cardiac output (OR per 1L/min greater, 0.66; 95% CI, 0.44-1.00; P=0.05) were independently associated with clinically significant arrhythmias. LIMITATIONS Arrhythmia monitoring limited to 48 hours; small sample size; heterogeneous nature of the population, risk for residual confounding. CONCLUSIONS Arrhythmias, including clinically significant abnormal rhythms, were common. Tachyarrhythmias were more frequent during dialysis and the immediate postdialytic period. The relevance of these findings to clinical outcomes requires additional study.
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Affiliation(s)
- Jesper Moesgaard Rantanen
- Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Sam Riahi
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; AF Study Group, Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Erik Berg Schmidt
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; AF Study Group, Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Peter Søgaard
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Jeppe Hagstrup Christensen
- Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Chang TIH, Liu S, Airy M, Niu J, Turakhia MP, Flythe JE, Montez-Rath ME, Winkelmayer WC. Blood Pressure and Incident Atrial Fibrillation in Older Patients Initiating Hemodialysis. Clin J Am Soc Nephrol 2019; 14:1029-1038. [PMID: 31175104 PMCID: PMC6625626 DOI: 10.2215/cjn.13511118] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 05/06/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES We examined the association of predialysis systolic and diastolic BP and intradialytic hypotension with incident atrial fibrillation in older patients initiating hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We used the US Renal Data System linked to the records of a large dialysis provider to identify patients aged ≥67 years initiating hemodialysis between January 2006 and October 2011. We examined quarterly average predialysis systolic BP, diastolic BP, and proportion of sessions with intradialytic hypotension (i.e., nadir systolic BP <90 mm Hg). We applied an extended Cox model to compute adjusted hazard ratios (HRs) of each exposure with incident atrial fibrillation. RESULTS Among 17,003 patients, 3785 developed atrial fibrillation. When comparing predialysis systolic BP to a fixed reference of 140 mm Hg, lower predialysis systolic BP was associated with a higher hazard of atrial fibrillation, whereas higher systolic BP was associated with a lower hazard of atrial fibrillation. When comparing across a range of systolic BP for two hypothetical patients with similar measured covariates, the association varied by mean systolic BP: at systolic BP 190 mm Hg, each 10 mm Hg lower systolic BP was associated with lower atrial fibrillation hazard (HR, 0.94; 95% confidence interval, 0.90 to 1.00), whereas at systolic BP 140 mm Hg, a 10 mm Hg lower systolic BP was associated with a higher atrial fibrillation hazard (HR, 1.12; 95% confidence interval, 1.10 to 1.14). Lower diastolic BP was associated with higher atrial fibrillation hazards. Intradialytic hypotension was weakly associated with atrial fibrillation. CONCLUSIONS In this observational study of older patients initiating hemodialysis, lower predialysis systolic BP and diastolic BP were associated with higher incidence of atrial fibrillation.
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Affiliation(s)
| | | | - Medha Airy
- Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, Texas
| | - Jingbo Niu
- Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, Texas
| | - Mintu P Turakhia
- Cardiovascular Medicine, Stanford University, Stanford, California.,Division of Cardiovascular Medicine, Palo Alto Veterans Affairs Medical Center, Palo Alto, California; and
| | - Jennifer E Flythe
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina (UNC) Kidney Center, UNC School of Medicine, Chapel Hill, North Carolina
| | | | - Wolfgang C Winkelmayer
- Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, Texas;
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Tumlin JA, Roy-Chaudhury P, Koplan BA, Costea AI, Kher V, Williamson D, Pokhariyal S, Charytan DM. Relationship between dialytic parameters and reviewer confirmed arrhythmias in hemodialysis patients in the monitoring in dialysis study. BMC Nephrol 2019; 20:80. [PMID: 30836948 PMCID: PMC6402171 DOI: 10.1186/s12882-019-1212-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 01/14/2019] [Indexed: 01/03/2023] Open
Abstract
Background Hemodialysis patients have high rates of sudden death, but relationships between serum electrolytes, the dialysis prescription, and intra-dialytic shifts in fluid and electrolyte with arrhythmia are uncertain. Methods We analyzed sixty-six hemodialysis patients who underwent loop recorder implantation with continuous electrocardiographic monitoring, weekly to bi-weekly testing of pre- and post-dialysis electrolytes, and detailed capture of dialysis prescription and flow sheet data for 6 months. The incidence rate ratio (IRR) of reviewer confirmed arrhythmias (RCA) during dialysis through 8 h after dialysis and associations with serum chemistries and dialytic parameters were assessed using adjusted, negative-binomial regression. Results Among 66 individuals with a mean age of 56 years, 12,480 events were detected in 64 (97%) patients. RCA nadired 12–24 h after dialysis and increased during the final 12 h of the inter-dialytic interval through the first 8 h after dialysis. Higher pre-dialysis serum magnesium concentration was associated with lower incidence rate ratio for arrythmia (IRR per 1 mg/dL increase 0.49, 95% CI; 0.25, 0.94), as was dialysate calcium concentration > 2.5 mEq/L vs. 2.5 mEq/L (IRR 0.52, 95% CI: 0.39, 0.70). Neither intradialytic serum potassium nor weight change were significantly associated with RCA rate. However, there was effect modification such that arrhythmia rate was maximal with concurrently high intradialytic volume and potassium removal (Pinteraction = 0.01). Conclusions Intra and post-dialytic arrhythmias are common in hemodialysis. Additional studies designed to further elucidate whether modification of the serum magnesium concentration, dialysate calcium concentration, and the extent of intradialytic potassium and fluid removal reduces the risk of per-dialytic arrhythmia are warranted. Trial registration Clinicaltrials.gov NCT01779856. Prospectively registered on January 22, 2013. Electronic supplementary material The online version of this article (10.1186/s12882-019-1212-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- James A Tumlin
- NephroNet Clinical Research Consortium, Atlanta, GA, USA
| | - Prabir Roy-Chaudhury
- University of Arizona Health Sciences and Southern Arizona VA Health Care System, Tuscon, AZ, USA
| | | | | | - Vijay Kher
- Medanta Kidney & Urology Institute, Medanta - The Medicity, Gurgaon, India
| | - Don Williamson
- Southeastern Clinical Research Institute, Augusta, GA, USA
| | - Saurabh Pokhariyal
- Department of Nephrology & Renal Transplantation, HCMCT Manipal Hospital Pvt. Ltd, Dwarka, Delhi, India
| | - David M Charytan
- Nephrology Division, New York University School of Medicine and NYU Langone Medical Center, New York, NY, USA.
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Sitaula S, Kaul P, Aggarwal V. Hemodialysis-induced bradycardia, "a plumbing issue": Resolved with catheter repositioning. Hemodial Int 2019; 23:E65-E68. [PMID: 30773834 DOI: 10.1111/hdi.12714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 09/26/2018] [Accepted: 09/27/2018] [Indexed: 11/29/2022]
Abstract
Sudden cardiac death (SCD) is reported as leading cause of death in patients on chronic hemodialysis. Arrhythmias are proposed to be a major predisposing factor for SCD. However, triggers for potentially lethal arrhythmias are not well understood. Here we describe a case of 72-year-old man on chronic hemodialysis via permanent Central venous catheter (CVC) who was admitted for evaluation after unwitnessed fall. Within 10 minutes of his first routine dialysis session in the hospital, he had cardiac-arrest. He was successfully resuscitated within 3 minutes. The next day, fifteen minutes into the dialysis session, he had bradycardia with telemetry demonstrating long sinus pause and he lost consciousness. After few minutes of Advanced Cardiac Life Support (ACLS) he regained pulse and consciousness. Further review of the chest X-ray revealed the tip of CVC to be directly touching the distal Superior Vena Cava (SVC) wall. We felt the catheter tip may have migrated after the fall and now is irritating the Sinoatrial node and triggering bradyarrhythmia. Next day, the CVC was exchanged, and the tip was placed higher up in superior vena-cava. After repositioning, we started him on dialysis under intensive monitoring, and he tolerated well without any arrhythmia. Subsequent dialysis was uneventful. We describe a case of recurrent symptomatic intra-dialytic bradycardia due to abnormal positioning of CVC that resolved after the repositioning of the catheter. This case in addition to similar case in nondialysis settlings provides additional insights into mechanisms of fatal arrhythmias in hemodialysis patient having CVC.
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Affiliation(s)
- Subhas Sitaula
- Department of Medicine, Division of Pulmonary and Critical Care, State University of New York (SUNY) Upstate Medical University, Syracuse, New York
| | - Pratibha Kaul
- Department of Medicine, Division of Pulmonary and Critical Care, State University of New York (SUNY) Upstate Medical University, Syracuse, New York
| | - Vikram Aggarwal
- Department of Medicine, Division of Nephrology, State University of New York (SUNY) Upstate Medical University, Syracuse, New York
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Niu J, Shah MK, Perez JJ, Airy M, Navaneethan SD, Turakhia MP, Chang TI, Winkelmayer WC. Dialysis Modality and Incident Atrial Fibrillation in Older Patients With ESRD. Am J Kidney Dis 2018; 73:324-331. [PMID: 30449517 DOI: 10.1053/j.ajkd.2018.09.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 09/07/2018] [Indexed: 01/31/2023]
Abstract
RATIONALE & OBJECTIVE Atrial fibrillation (AF) is common in patients with kidney failure treated by maintenance dialysis. Whether the incidence of AF differs between patients receiving hemodialysis and peritoneal dialysis is uncertain. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Using the US Renal Data System, we identified older patients (≥67 years) with Medicare Parts A and B who initiated dialysis therapy (1996-2011) without a diagnosis of AF during the prior 2 years. EXPOSURE Dialysis modality at incident end-stage renal disease (ESRD) and maintained for at least 90 days. OUTCOME Patients were followed up for 36 months or less for a new diagnosis of AF. ANALYTICAL APPROACH Time-to-event analysis using multivariable Cox proportional hazards regression to estimate cause-specific HRs while censoring at modality switch, kidney transplantation, or death. RESULTS Overall, 271,722 older patients were eligible; 17,487 (6.9%) were treated with peritoneal dialysis, and 254,235 (93.1%), with hemodialysis, at the onset of ESRD. During 406,225 person-years of follow-up, 69,705 patients had AF newly diagnosed. Because the proportionality assumption was violated, we introduced an interaction term between time (first 90 days vs thereafter) and modality. The AF incidence during the first 90 days was 187/1,000 person-years on peritoneal dialysis therapy and 372/1,000 person-years on hemodialysis therapy. Patients on peritoneal dialysis therapy had an adjusted 39% (95% CI, 34%-43%) lower incidence of AF than those on hemodialysis therapy. From day 91 onward, AF incidence was ∼140/1,000 person-years with no major difference between modalities. LIMITATIONS Residual confounding from unobserved differences between exposure groups; ascertainment of AF from billing claims; study of first modality may not generalize to patients switching modalities; uncertain generalizability to younger patients. CONCLUSIONS Although patients initiating dialysis therapy using peritoneal dialysis had a lower AF incidence during the first 90 days of ESRD, there was no major difference in AF incidence thereafter. The value of interventions to reduce the early excess AF risk in patients receiving hemodialysis may warrant further study.
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Affiliation(s)
- Jingbo Niu
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Maulin K Shah
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Jose J Perez
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Medha Airy
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Sankar D Navaneethan
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Mintu P Turakhia
- Cardiovascular Division, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Tara I Chang
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA
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Roy-Chaudhury P, Tumlin JA, Koplan BA, Costea AI, Kher V, Williamson D, Pokhariyal S, Charytan DM, Williamson D, Roy-Chaudhury P, Tumlin J, Kher V, Reddy V, Prakash KC, Charytan D, Tiwari SC, Pokhariyal S, Podoll A, Jasuja S, Walters GL, Wangsnes K, Costea A, Tombul S, Singh B, Mishra B, Yalagudri S, Shelke A, Narasimhan C, Karthigesan A, Oomman A, Kumar KP, Koplan B, Kaul U, Ghose T, Gupta R, Sethi A, Kumar N, Hariharan R, Sardana R, Wahab A, Khanna N, Smith M, Kamath S, Galphin C, Sodhi P, Chakravarthy R, Budithi SR, McCausland F, Gulati S, Dijoo M, Singh U, Jain S, Saxena V, Sagar G, Charytan D, Fissell R, Foley R, Herzog CA, McCullough P, Rogers JD, Tumlin JA, Zimetbaum P, Assar M, Kremers M, Winkelmayer WC. Primary outcomes of the Monitoring in Dialysis Study indicate that clinically significant arrhythmias are common in hemodialysis patients and related to dialytic cycle. Kidney Int 2018; 93:941-951. [DOI: 10.1016/j.kint.2017.11.019] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 11/07/2017] [Accepted: 11/09/2017] [Indexed: 12/15/2022]
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Use of oral anticoagulants in patients with atrial fibrillation and renal dysfunction. Nat Rev Nephrol 2018; 14:337-351. [PMID: 29578207 DOI: 10.1038/nrneph.2018.19] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Atrial fibrillation (AF) and chronic kidney disease (CKD) are increasingly prevalent in the general population and share common risk factors such as older age, hypertension and diabetes mellitus. The presence of CKD increases the risk of incident AF, and, likewise, AF increases the risk of CKD development and/or progression. Both conditions are associated with substantial thromboembolic risk, but patients with advanced CKD also exhibit a paradoxical increase in bleeding risk. In the landmark randomized clinical trials that compared non-vitamin K antagonist oral anticoagulants (NOACs) with warfarin for thromboprophylaxis in patients with AF, the efficacy and safety of NOACs in patients with mild-to-moderate CKD were similar to those in patients without CKD. Dose adjustment of NOACs as per the prescribing label is required in this population. Owing to limited trial data, evidence-based recommendations for the management of patients with AF and severe CKD or end-stage renal disease on dialysis are lacking. Observational cohort studies have reported conflicting results, and the management of these particularly vulnerable patients remains challenging and requires careful assessment of stroke and bleeding risk and, where appropriate, use of warfarin with good-quality anticoagulation control.
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[Anticoagulation in patients with chronic kidney disease : Recommendations from the working group "Heart-Kidney" of the German Cardiac Society and the German Society of Nephrology]. Internist (Berl) 2018; 58:512-521. [PMID: 28396914 DOI: 10.1007/s00108-017-0220-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Indications for anticoagulation are thromboembolic events, prosthetic heart valves, and atrial fibrillation with a corresponding risk score. Clinical trials have excluded patients with advanced chronic kidney disease and these data cannot be always generalized to patients with chronic kidney disease. Non-vitamin K antagonist oral anticoagulants (NOACs) are mostly not recommended or are contraindicated in advanced stages of chronic kidney disease. Observational studies have shown that dialysis patients with atrial fibrillation do not profit from coumarin anticoagulants; prospective studies are lacking.
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Jaroszyński A, Jaroszyńska A, Dąbrowski W, Zaborowski T, Stepulak A, Iłżecki M, Zubilewicz T. Factors influencing P terminal force in lead V1 of the ECG in hemodialysis patients. Arch Med Sci 2018; 14:257-264. [PMID: 29593797 PMCID: PMC5868674 DOI: 10.5114/aoms.2017.65926] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 11/17/2015] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Atrial fibrillation (AF) is a highly prevalent arrhythmia in hemodialysis (HD) patients, and an HD session may be a trigger for AF episodes. An abnormal P-terminal force in lead V1 (PTFV1) may predict new-onset AF in HD patients. The aim of the study was to assess the influence of the HD process on PTFV1 and to evaluate possible factors influencing PTFV1 in a group of selected HD patients. MATERIAL AND METHODS One hundred and fifty-three selected HD patients entered the study. Blood chemistry, electrocardiography, and impedance cardiography were evaluated before and after HD. Echocardiography was performed on the morning after dialysis. Abnormal PTFV1 was defined as PTFV1 > 40 mm × ms. RESULTS Abnormal PTFV1 was found in 35.3% of patients before dialysis and in 48.4% of patients after dialysis. The results of multiple regression analysis revealed that the independent predictors of pre-dialysis abnormal PTFV1 were: left atrial volume index (p = 0.002), left ventricular mass index (p = 0.014), and pre-dialysis thoracic fluid content (p = 0.021) values. The independent predictors of HD-induced abnormal PTFV1 values were larger differences between pre-dialysis and post-dialysis values of serum potassium (p < 0.001) and mean arterial pressure (p = 0.008). CONCLUSIONS Abnormal PTFV1 is prevalent in HD patients. The HD process adversely affects PTFV1 values. Pre-dialysis abnormal PTFV1 is mainly associated with structural heart abnormalities and hydration status. HD-induced abnormal PTFV1 is associated predominantly with serum potassium changes as well as HD-induced hypotension. Our results suggest possible risk factors for AF; however, their clinical significance needs to be confirmed in follow-up studies.
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Affiliation(s)
- Andrzej Jaroszyński
- Institute of Medical Sciences, Jan Kochanowski University, Kielce, Poland
- Department of Family Medicine, Medical University of Lublin, Lublin, Poland
| | - Anna Jaroszyńska
- Department of Cardiology, Medical University of Lublin, Lublin, Poland
| | - Wojciech Dąbrowski
- Department of Anesthesiology and Intensive Care, Medical University of Lublin, Lublin, Poland
| | - Tomasz Zaborowski
- Institute of Medical Sciences, Jan Kochanowski University, Kielce, Poland
| | - Andrzej Stepulak
- Department of Biochemistry and Molecular Biology, Medical University of Lublin, Lublin, Poland
| | - Marek Iłżecki
- Department of Vascular Surgery, Medical University of Lublin, Lublin, Poland
| | - Tomasz Zubilewicz
- Department of Vascular Surgery, Medical University of Lublin, Lublin, Poland
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46
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Parker K, Mitra S, Thachil J. Is anticoagulating haemodialysis patients with non-valvular atrial fibrillation too risky? Br J Haematol 2018; 181:725-736. [PMID: 29468649 DOI: 10.1111/bjh.15144] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
There is an increasing understanding of the risks from atrial fibrillation (AF) in the current era. In patients with end-stage renal disease (ESRD) on dialysis, the prevalence of AF is significantly higher compared to the general population and those with earlier stages of CKD. Although anticoagulation of these patients may seem appropriate, there is a lack of conclusive evidence that it provides the same protection from thromboembolic complications as it does in patients not on dialysis. In addition, the increased risk of bleeding in patients requiring dialysis makes the use of anticoagulants less favourable. This article aims to discuss the problem of AF in dialysis patients, summarise the current evidence around the use of oral anticoagulants for AF in ESRD and provide some practical suggestions on management of AF in the haemodialysis population.
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Affiliation(s)
- Kathrine Parker
- Department of Pharmacy, Manchester Royal Infirmary, Manchester, UK
| | - Sandip Mitra
- Department of Renal Medicine, Manchester Institute of Nephrology and Transplantation, Manchester, UK
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
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47
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Abuhasira R, Mizrakli Y, Shimony A, Novack V, Shnaider A, Haviv YS. Atrial Fibrillation Characteristics in Patients on Haemodialysis vs. Peritoneal Dialysis. Sci Rep 2018; 8:2976. [PMID: 29445225 PMCID: PMC5813026 DOI: 10.1038/s41598-018-21229-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 01/31/2018] [Indexed: 01/19/2023] Open
Abstract
Atrial fibrillation (AF) is highly prevalent in dialysis patients, however whether its impact differs between patients on haemodialysis (HD) vs. peritoneal dialysis (PD) is unknown. We aimed to compare the association of AF and clinical outcomes in different dialysis modalities. We performed a population based retrospective cohort study, including adult patients who initiated dialysis between the years 2002 and 2015. Clinical, echocardiographic and laboratory data were reviewed and correlated with outcomes in HD vs. PD. During the study period, 1,130 patients began dialysis. Of the 997 patients without AF before dialysis initiation, 17% developed new-onset AF after the initiation of dialysis (17.3% of HD vs. 13.7% of PD patients, p = 0.27). Using multivariate analysis, only enlarged left atrium at dialysis initiation (hazard ratio (HR) 2.82, CI95% 2.00–3.99) and age (HR 1.04, CI95% 1.03–1.06) were significantly associated with AF. Dialysis modality was not a significant predictor of AF in either univariate or multivariate analysis. In conclusion, our study demonstrated that AF is common in dialysis patients irrespective of modality. In our cohort, the risk factors associated with AF were older age and enlarged left atrium. AF was associated with increased rates of heart failure and mortality, but not stroke.
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Affiliation(s)
- Ran Abuhasira
- The Joyce and Irving Goldman Medical School, Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel. .,Clinical Research Centre, Soroka University Medical Centre, Beer-Sheva, Israel.
| | - Yuval Mizrakli
- The Joyce and Irving Goldman Medical School, Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel.,Clinical Research Centre, Soroka University Medical Centre, Beer-Sheva, Israel
| | - Avi Shimony
- Department of Cardiology, Soroka University Medical Centre, Beer-Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel
| | - Victor Novack
- Clinical Research Centre, Soroka University Medical Centre, Beer-Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel
| | - Alla Shnaider
- Department of Nephrology, Soroka University Medical Centre, Beer-Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel
| | - Yosef S Haviv
- Department of Nephrology, Soroka University Medical Centre, Beer-Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel
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48
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Lin J, Cheng Z, Ding X, Qian Q. Acid-Base and Electrolyte Managements in Chronic Kidney Disease and End-Stage Renal Disease: Case-Based Discussion. Blood Purif 2018; 45:179-186. [PMID: 29478053 DOI: 10.1159/000485155] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Acid-base and electrolyte alterations are common in patients with chronic kidney disease (CKD) and end-stage kidney failure (ESRD). The alterations become more complex as CKD advances to ESRD, leading to morbidity and mortality. Three cases are presented illustrating some key prototypic features in CKD and ESRD. Each is accompanied by discussion of pathophysiology, diagnosis, and treatment options. Newer investigational results are integrated into the existing body of knowledge. Although rigorous assessment of various dialysis prescriptions is scanty, in its current state, instituting a well thought-out, multi-pronged management plan to minimize CKD/ESRD and dialysis-related electrolyte and acid-base disruptions is appropriate. There is a pressing need for prospective interventional trials in the future.
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Affiliation(s)
- Jing Lin
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhen Cheng
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Xiaoqiang Ding
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qi Qian
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, College of Medicine, Rochester, Minnesota, USA
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49
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Sou'ub RM, Masa'Deh R, AbuRuz ME, Alhalaiqa F. Parental psychological stress: Children on hemodialysis. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2018. [DOI: https://doi.org/10.1016/j.ijans.2018.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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50
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Sou'ub RM, Masa'Deh R, AbuRuz ME, Alhalaiqa F. Parental psychological stress: Children on hemodialysis. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2018. [DOI: 10.1016/j.ijans.2018.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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