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Jyrkilä H, Kaartinen K, Martola L, Halminen O, Haukka J, Linna M, Mustonen P, Putaala J, Teppo K, Kinnunen J, Hartikainen J, Airaksinen KEJ, Lehto M. Comorbidity and Medication Trends in Chronic Kidney Disease and Incident Atrial Fibrillation: A Nationwide Cohort Study. Nephron Clin Pract 2024:1-13. [PMID: 38861935 DOI: 10.1159/000539603] [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: 12/14/2023] [Accepted: 05/25/2024] [Indexed: 06/13/2024] Open
Abstract
INTRODUCTION Chronic kidney disease (CKD) is associated with an increased incidence of atrial fibrillation (AF). Also, patients with AF are prone to adverse kidney outcomes. We examined comorbidities and medication use in patients with CKD and incident AF. METHODS The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) is a nationwide retrospective register-linkage study including data from 168,233 patients with incident AF from 2007 to 2018, with laboratory data from 2010 onwards. Estimated glomerular filtration rate (eGFR) was available for 124,936 patients. The cohort was divided into 5 CKD stages with separate groups for dialysis and kidney transplantation. RESULTS At AF diagnosis eGFR <60 mL/min/1.73 m2 was found in 27%, while 318 (0.3%) patients were on dialysis, and 188 (0.2%) had a functioning kidney transplant. Lowering eGFR yielded more comorbidities and medications. During 2010-2018 in patients with eGFR <60 mL/min/1.73 m2 prevalence of hypertension, dyslipidaemia, and diabetes increased from 82 to 88%, from 50 to 66% and from 25 to 33%, respectively (<0.001). Throughout the observation period, lipid-lowering medication was underused. CONCLUSION More than one-fourth of patients with incident AF also had CKD stage 3-5 (eGFR <60 mL/min/1.73 m2). Both comorbidities and medication use increased with worsening kidney function. Prevalence of major cardiovascular (CV) risk factors increased during 2010-2018, but the use of survival-affecting medications, such as lipid-lowering medication, was suboptimal at all stages of CKD. More attention should be given to the optimal treatment of risk factors in this high CV risk population.
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Affiliation(s)
- Heini Jyrkilä
- Helsinki University Hospital, Abdominal Center, Department of Nephrology and University of Helsinki, Helsinki, Finland
| | - Kati Kaartinen
- Helsinki University Hospital, Abdominal Center, Department of Nephrology and University of Helsinki, Helsinki, Finland
| | - Leena Martola
- Helsinki University Hospital, Abdominal Center, Department of Nephrology and University of Helsinki, Helsinki, Finland
| | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
| | - Jari Haukka
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Miika Linna
- University of Eastern Finland, Kuopio, Finland
| | - Pirjo Mustonen
- Department of Internal Medicine, Central Finland Health Care District, Jyväskylä, Finland
| | - Jukka Putaala
- Helsinki University Hospital, Department of Neurology and University of Helsinki, Helsinki, Finland
| | - Konsta Teppo
- Turku University Hospital, Department of Cardiology and University of Turku, Turku, Finland
| | - Janne Kinnunen
- Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Juha Hartikainen
- Kuopio University Hospital, Heart Center, Department of Cardiology and University of Eastern Finland, Kuopio, Finland
| | - K E Juhani Airaksinen
- Turku University Hospital, Department of Cardiology and University of Turku, Turku, Finland
| | - Mika Lehto
- Jorvi Hospital, HUS Helsinki University Hospital, Espoo, Finland
- University of Helsinki, Helsinki, Finland
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Westreich R, Tsaban G, Barrett O, Kezerle L, Tsadok MA, Akriv A, Bachrach A, Leventer-Roberts M, Senderey AB, Haim M. Estimated glomerular filtration rate and the risk of stroke in individuals with diabetes mellitus and atrial fibrillation insight from a large contemporary population study. J Thromb Thrombolysis 2024; 57:322-329. [PMID: 37945939 DOI: 10.1007/s11239-023-02913-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/22/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Diabetes mellitus (DM) is associated with increased risk of embolic complications in non-valvular atrial fibrillation (NVAF). Impaired renal function (IRF) increases the risk of stroke as well, but this finding is not consistent among all studies. Our aim was to assess the incidence rates and risk of ischemic stroke and mortality by baseline Estimated Glomerular Filtration Rate (eGFR) levels Among individuals with AF and DM. METHODS A prospective, historical cohort study using the Clalit Health Services electronic medical records database. Among patients with AF and DM, we compared three groups according to eGFR levels: eGFR ≥ 60, between 30 and 60, and ≤ 30 (mL/min/1.73m2). RESULTS A total of 17,567 cases were included in the final analysis; of them, 11,013 (62.7%) had eGFR ≥ 60, 4930 (28%) had eGFR between 30 and 60, and 1624 (9.24%) with eGFR ≤ 30. The incidence of stroke per 100 person-years in the three study groups was: 1.88, 2.69, and 3.34, respectively (p < 0.001). IRF was associated with increased risk of stroke in univariate analysis, but not after multivariate adjustment (Adjusted Hazard Ratio (AHR) 0.96 {95%CI; 0.74-1.25} for eGFR 30-60 and 0.96 {95%CI; 0.60-1.55} for eGFR ≤ 30). Mortality per 100 person-years was 10.78, 21.49, and 41.55, respectively (p < 0.001). IRF was associated with increased mortality risk in univariate analysis, as well as in multivariate analysis (AHR 1.08 {95%CI; 0.98-1.18} for eGFR 30-60, and 1.59 {95%CI; 1.37-1.85} for eGFR ≤ 30. CONCLUSION In patients with NVAF and DM, IRF was not associated with an increased risk of stroke, but severe IRF (eGFR ≤ 30) was associated with increased mortality risk.
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Affiliation(s)
- Roi Westreich
- Cardiac Electrophysiology and Pacing, Cardiology Department, Soroka Medical Center, Ben- Gurion University of the Negev, PO Box 141, 84101, Beer-Sheva, Beer-Sheva, Israel.
| | - Gal Tsaban
- Cardiac Electrophysiology and Pacing, Cardiology Department, Soroka Medical Center, Ben- Gurion University of the Negev, PO Box 141, 84101, Beer-Sheva, Beer-Sheva, Israel
| | - Orit Barrett
- Cardiac Electrophysiology and Pacing, Cardiology Department, Soroka Medical Center, Ben- Gurion University of the Negev, PO Box 141, 84101, Beer-Sheva, Beer-Sheva, Israel
| | - Louise Kezerle
- Cardiac Electrophysiology and Pacing, Cardiology Department, Soroka Medical Center, Ben- Gurion University of the Negev, PO Box 141, 84101, Beer-Sheva, Beer-Sheva, Israel
| | - Meytal Avgil Tsadok
- Clalit Research Institute, Clalit Health Services, Chief Physician's Office, Tel Aviv, Israel
| | - Amichay Akriv
- Clalit Research Institute, Clalit Health Services, Chief Physician's Office, Tel Aviv, Israel
| | - Asaf Bachrach
- Clalit Research Institute, Clalit Health Services, Chief Physician's Office, Tel Aviv, Israel
| | - Maya Leventer-Roberts
- Clalit Research Institute, Clalit Health Services, Chief Physician's Office, Tel Aviv, Israel
| | - Adi Berliner Senderey
- Clalit Research Institute, Clalit Health Services, Chief Physician's Office, Tel Aviv, Israel
| | - Moti Haim
- Cardiac Electrophysiology and Pacing, Cardiology Department, Soroka Medical Center, Ben- Gurion University of the Negev, PO Box 141, 84101, Beer-Sheva, Beer-Sheva, Israel
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Ha JT, Scaria A, Andrade J, Badve SV, Birks P, Bota SE, Campain A, Djurdjev O, Garg AX, Harel Z, Hemmelgarn B, Hockham C, James MT, Jardine MJ, Lam D, Levin A, McArthur E, Ravani P, Shao S, Sood MM, Tan Z, Tangri N, Whitlock R, Gallagher M, Jun M. Safety and Effectiveness of Rivaroxaban Versus Warfarin Across GFR Levels in Atrial Fibrillation: A Population-Based Study in Australia and Canada. Kidney Med 2023; 5:100675. [PMID: 37492112 PMCID: PMC10363562 DOI: 10.1016/j.xkme.2023.100675] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023] Open
Abstract
Rationale & Objective The benefit-risk profile of rivaroxaban versus warfarin for atrial fibrillation (AF) in patients with chronic kidney disease is uncertain. We compared rivaroxaban with warfarin across the range of kidney function in adults with AF. Study Design Multicenter retrospective cohort. Setting & Participants Adults with AF and a measure of estimated glomerular filtration rate (eGFR); using administrative data from 5 jurisdictions across Australia and Canada (2011-2018). Kidney function was categorized as eGFR ≥60, 45-59, 30-44, and <30 mL/min/1.73 m2. Patients receiving dialysis and kidney transplant recipients were excluded. Exposures New dispensation of either rivaroxaban or warfarin. Outcomes Composite (1) effectiveness outcome (all-cause death, ischemic stroke, or transient ischemic attack) and (2) major bleeding events (intracranial, gastrointestinal, or other) at 1 year. Analytical Approach Cox proportional hazards models accounting for propensity score matching were performed independently in each jurisdiction and then pooled using random-effects meta-analysis. Results 55,568 patients (27,784 rivaroxaban-warfarin user matched pairs; mean age 74 years, 46% female, 33.5% with eGFR <60 mL/min/1.73 m2) experienced a total of 4,733 (8.5%) effectiveness and 1,144 (2.0%) bleeding events. Compared to warfarin, rivaroxaban was associated with greater or similar effectiveness across a broad range of kidney function (pooled HRs of 0.72 [95% CI, 0.66-0.78], 0.78 [95% CI, 0.58-1.06], 0.70 [95% CI, 0.57-0.87], and 0.78 [95% CI, 0.62-0.99]) for eGFR ≥60, 45-59, 30-44, and <30 mL/min/1.73 m2, respectively). Rivaroxaban was also associated with similar risk of major bleeding across all eGFR categories (pooled HRs of 0.75 [95% CI, 0.56-1.00], 1.01 [95% CI, 0.79-1.30], 0.87 [95% CI, 0.66-1.15], and 0.63 [95% CI, 0.37-1.09], respectively). Limitations Unmeasured treatment selection bias and residual confounding. Conclusions In adults with AF, rivaroxaban compared with warfarin was associated with lower or similar risk of all-cause death, ischemic stroke and transient ischemic attack and similar risk of bleeding across a broad range of kidney function. Plain-Language Summary This real-world study involved a large cohort of 55,568 adults with atrial fibrillation from 5 jurisdictions across Australia and Canada. It showed that the favorable safety (bleeding) and effectiveness (stroke or death) profile of rivaroxaban compared with warfarin was consistent across different levels of kidney function. This study adds important safety data on the use of rivaroxaban in patients with reduced kidney function, including those with estimated glomerular filtration rate <30 mL/min/1.73 m2 in whom the risks and benefits of rivaroxaban use is most uncertain. Overall, the study supports the use of rivaroxaban as a safe and effective alternative to warfarin for atrial fibrillation across differing levels of kidney function.
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Affiliation(s)
- Jeffrey T. Ha
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Anish Scaria
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Jason Andrade
- University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Sunil V. Badve
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Peter Birks
- University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Anna Campain
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | | | - Amit X. Garg
- ICES, Ontario, Canada
- Department of Medicine, Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Ziv Harel
- Division of Nephrology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Brenda Hemmelgarn
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Carinna Hockham
- The George Institute for Global Health, U.K., Imperial College London, London, United Kingdom
| | - Matthew T. James
- Cumming School of Medicine, Division of Nephrology, University of Calgary, Alberta, Canada
- Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta, Canada
| | - Meg J. Jardine
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Dickson Lam
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Adeera Levin
- University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
- BC Provincial Renal Agency, Vancouver, British Columbia, Canada
| | | | - Pietro Ravani
- Cumming School of Medicine, Division of Nephrology, University of Calgary, Alberta, Canada
| | - Selena Shao
- BC Provincial Renal Agency, Vancouver, British Columbia, Canada
| | - Manish M. Sood
- The Ottawa Hospital Research Institute and Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Zhi Tan
- Cumming School of Medicine, Division of Nephrology, University of Calgary, Alberta, Canada
| | - Navdeep Tangri
- Department of Internal Medicine, University of Manitoba, Max Rady College of Medicine, Winnipeg, Manitoba, Canada
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Reid Whitlock
- Department of Internal Medicine, University of Manitoba, Max Rady College of Medicine, Winnipeg, Manitoba, Canada
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Martin Gallagher
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
- Liverpool Clinical School, UNSW Sydney, Sydney, NSW, Australia
| | - Min Jun
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
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Bansal N, Zelnick LR, An J, Harrison TN, Lee MS, Singer DE, Sung SH, Fan D, Go AS. Association of Kidney Function With Risk of Adverse Effects of Therapies for Atrial Fibrillation. Kidney Int Rep 2023; 8:606-618. [PMID: 36938096 PMCID: PMC10014389 DOI: 10.1016/j.ekir.2022.12.002] [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: 11/23/2022] [Accepted: 12/05/2022] [Indexed: 12/15/2022] Open
Abstract
Introduction Atrial fibrillation (AF) is common in chronic kidney disease (CKD) and is treated with rate control medications, antiarrhythmic medications, as well as anticoagulation and procedures, each of which have associated risks. We aimed to evaluate the association of CKD status with the risks of adverse effects after initiation of AF therapies. Methods This was a cohort study of community-based adults who newly initiated rate control medications, antiarrhythmic medications, warfarin, direct oral anticoagulants (DOACs) or received AF procedures in the 1 year after diagnosis of AF. Baseline estimated glomerular filtration rate (eGFR) was calculated using outpatient serum creatinine measures. Adverse effects within 1 year related to each AF therapy or within 1 month of an AF procedure were ascertained from vital sign databases, electrocardiograms (ECGs), and administrative codes. Fine-Gray hazard models were used to study the association of eGFR categories with risk of adverse effects for each AF therapy. Results Among 115,564 patients with incident AF, lower eGFR (vs. eGFR ≥60 ml/min per 1.73 m2) was significantly associated with higher adjusted risk of adverse effects after initiation of rate control therapies (most commonly hypotension and bradycardia) as follows: eGFR 45-59 (hazard ratio [HR] 1.14, 95% confidence interval [CI] 1.07-1.22), 30-44 (HR 1.15, 95% CI 1.06-1.25), and 15-29 (HR 1.29, 95% CI: 1.12-1.47) ml/min per 1.73 m2. Lower eGFR was associated with higher adjusted risk of adverse effects (most commonly prolonged QRS and QTc intervals) after initiation of an antiarrhythmic medication (vs. eGFR >60 ml/min per 1.73 m2) as follows: eGFR 45-59 (HR 1.12, 95% CI 1.01-1.23) and eGFR<15 (HR 1.43, 95% CI 1.01-2.01) ml/min per 1.73 m2. Conclusion There was a graded association between lower eGFR and risk of major bleeding with warfarin use, with the greatest risk among those with eGFR <15 ml/min per 1.73 m2 (HR of 2.93, 95% CI 1.99-4.30). There was no association of eGFR with major bleeding in patients receiving DOACs. Rates of adverse effects within 1 month of an AF procedure were low among patients with (n = 18) and without (n = 41) CKD and was underpowered for further analyses. In conclusion, lower eGFR was associated with significantly higher risks of adverse effects after initiation of commonly used therapies to treat AF. These data may help inform the complex therapeutic decisions in patients with CKD and AF.
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Affiliation(s)
- Nisha Bansal
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
- Correspondence: Nisha Bansal, Division of Nephrology, University of Washington, 908 Jefferson St, 3rd floor, Seattle, Washington 98104, USA.
| | - Leila R. Zelnick
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Jaejin An
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Teresa N. Harrison
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Ming-Sum Lee
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Daniel E. Singer
- Clinical Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Sue Hee Sung
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Dongjie Fan
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Alan S. Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
- Department of Medicine and Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
- Department of Medicine, Stanford University, Palo Alto, California, USA
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5
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Bansal N, Zelnick LR, Reynolds K, Harrison TN, Lee MS, Singer DE, Sung SH, Fan D, Go AS. Management of Adults with Newly Diagnosed Atrial Fibrillation with and without CKD. J Am Soc Nephrol 2022; 33:442-453. [PMID: 34921110 PMCID: PMC8819992 DOI: 10.1681/asn.2021060744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 12/06/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is highly prevalent in CKD and is associated with worse cardiovascular and kidney outcomes. Limited data exist on use of AF pharmacotherapies and AF-related procedures by CKD status. We examined a large "real-world" contemporary population with incident AF to study the association of CKD with management of AF. METHODS We identified patients with newly diagnosed AF between 2010 and 2017 from two large, integrated health care delivery systems. eGFR (≥60, 45-59, 30-44, 15-29, <15 ml/min per 1.73 m2) was calculated from a minimum of two ambulatory serum creatinine measures separated by ≥90 days. AF medications and procedures were identified from electronic health records. We performed multivariable Fine-Gray subdistribution hazards regression to test the association of CKD severity with receipt of targeted AF therapies. RESULTS Among 115,564 patients with incident AF, 34% had baseline CKD. In multivariable models, compared with those with eGFR >60 ml/min per 1.73 m2, patients with eGFR 30-44 (adjusted hazard ratio [aHR] 0.91; 95% CI, 0.99 to 0.93), 15-29 (aHR, 0.78; 95% CI, 0.75 to 0.82), and <15 ml/min per 1.73 m2 (aHR, 0.64; 95% CI, 0.58-0.70) had lower use of any AF therapy. Patients with eGFR 15-29 ml/min per 1.73 m2 had lower adjusted use of rate control agents (aHR, 0.61; 95% CI, 0.56 to 0.67), warfarin (aHR, 0.89; 95% CI, 0.84 to 0.94), and DOACs (aHR, 0.23; 95% CI, 0.19 to 0.27) compared with patients with eGFR >60 ml/min per 1.73 m2. These associations were even stronger for eGFR <15 ml/min per 1.73 m2. There was also a graded association between CKD severity and receipt of AF-related procedures (vs eGFR >60 ml/min per 1.73 m2): eGFR 30-44 ml/min per 1.73 (aHR, 0.78; 95% CI, 0.70 to 0.87), eGFR 15-29 ml/min per 1.73 m2 (aHR, 0.73; 95% CI, 0.61 to 0.88), and eGFR <15 ml/min per 1.73 m2 (aHR, 0.48; 95% CI, 0.31 to 0.74). CONCLUSIONS In adults with newly diagnosed AF, CKD severity was associated with lower receipt of rate control agents, anticoagulation, and AF procedures. Additional data on efficacy and safety of AF therapies in CKD populations are needed to inform management strategies.
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Affiliation(s)
- Nisha Bansal
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington
| | - Leila R. Zelnick
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California,Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Teresa N. Harrison
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Ming-Sum Lee
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Daniel E. Singer
- Clinical Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | - Sue Hee Sung
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Dongjie Fan
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Alan S. Go
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California,Division of Research, Kaiser Permanente Northern California, Oakland, California,Department of Medicine and Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California,Departments of Medicine, Stanford University, Palo Alto, California
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Pavlova TV. Renal Function Protection as an Important Component of a Comprehensive Approach to the Management of Patients with Atrial Fibrillation. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2022. [DOI: 10.20996/1819-6446-2021-12-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The increase in the life expectancy of the population is accompanied by an increase in the prevalence of diseases for which old and senile age are risk factors. Atrial fibrillation (AF) and chronic kidney disease (CKD) are two diseases that can coexist in a patient. The risk of ac thromboembolic and hemorrhagic events in this case increases due to the mutual aggravating influence of these diseases. In addition, these patients have a high incidence of coronary events, and cardiovascular complications are the main cause of death in patients with AF and CKD. Consequently, such patients require an integrated approach to treatment, and their management is a complex clinical task. The direct oral anticoagulant rivaroxaban has been most studied in a population of comorbid AF and CKD patients and has proven a high efficacy and safety profile in these patients in randomized controlled trials. In addition, rivaroxaban has shown a significant reduction in the risk of myocardial infarction in various patients, as well as the possibility of preserving renal function to a greater extent compared with warfarin therapy, and a possible positive effect on reducing the risk of cognitive impairment. A single dosing regimen can improve adherence to treatment, which is one of the key conditions for achieving the above effects. Thus, these factors make it possible to achieve comprehensive protection of comorbid patients with AF and CKD.
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7
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Revisiting risk prediction tools for death and end-stage renal disease in older patients with advanced chronic kidney disease: a prospective study. Int Urol Nephrol 2022; 54:1969-1976. [PMID: 34993891 DOI: 10.1007/s11255-021-03082-4] [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: 10/13/2021] [Accepted: 11/27/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Risk assessment tools for predicting mortality and end-stage renal disease (ESRD) in the elderly with CKD have received growing attention. However, integrating risk equations into a multidimensional approach of elderly with CKD stage 3b-4 is lacking. METHODS In this prospective observational study, we enrolled CKD stage 3b-4 patients aged ≥ 65 years. Bansal score for predicting mortality risk and Kidney Failure Risk Equation (KFRE) for estimating progression to ESRD were applied. Predicted outcome was compared with actual clinical end-points. All patients underwent comprehensive geriatric assessment (CGA), which is an interdisciplinary multidimensional process for geriatric evaluation and management. RESULTS Participants (N = 184) were divided into two groups, according to Bansal score: Group 1 (low-risk of death, Bansal score < 7, N = 69) and Group 2 (high-risk of death, Bansal score ≥ 7, N = 115). Group 2 displayed a substantially higher cardiovascular disease burden than Group 1 and was significantly more likely to be depressed and at risk of malnutrition, according to CGA. Thirty-seven patients died, and 16 started dialysis. Group 2 displayed significantly higher all-cause mortality. In the univariable Cox regression, Group 2 had a fourfold increase in the risk of all-cause mortality, as compared with Group 1 (HR = 4.29, 95% CI 1.88-10.26, P < 0.001). Multivariable stepwise Cox analysis showed that Bansal score above 7 remained significantly associated with all-cause mortality (HR = 3.96, 95% CI 1.68-9.29, P < 0.001). Group 2 also displayed higher event rates for dialysis initiation. In Group 1, only four patients started dialysis, and three out of them had a high-risk of progression at baseline, according to KFRE. CONCLUSIONS Using risk stratification tools and CGA in a population of elderly with advanced CKD, we found that two-thirds of the patients were at high risk of death, malnutrition and depression, with multimorbidity and four times worse probability of survival than those at lower risk of death.
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Chou CY, Chung FP, Chang HY, Lin YJ, Lo LW, Hu YF, Chao TF, Liao JN, Tuan TC, Lin CY, Chang TY, Liu CM, Wu CI, Huang SH, Chen CC, Cheng WH, Liu SH, Lugtu IC, Jain A, Feng AN, Chang SL, Chen SA. Prediction of Recurrent Atrial Tachyarrhythmia After Receiving Atrial Flutter Ablation in Patients With Prior Cardiac Surgery for Valvular Heart Disease. Front Cardiovasc Med 2021; 8:741377. [PMID: 34631838 PMCID: PMC8495322 DOI: 10.3389/fcvm.2021.741377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 08/25/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Surgical scars cause an intra-atrial conduction delay and anatomical obstacles that facilitate the perpetuation of atrial flutter (AFL). This study aimed to investigate the outcome and predictor of recurrent atrial tachyarrhythmia after catheter ablation in patients with prior cardiac surgery for valvular heart disease (VHD) who presented with AFL. Methods: Seventy-two patients with prior cardiac surgery for VHD who underwent AFL ablation were included. The patients were categorized into a typical AFL group (n = 45) and an atypical AFL group (n = 27). The endpoint was the recurrence of atrial tachyarrhythmia during follow-up. A multivariate analysis was performed to determine the predictor of recurrence. Results: No significant difference was found in the recurrence rate of atrial tachyarrhythmia between the two groups. Patients with concomitant atrial fibrillation (AF) had a higher recurrence of typical AFL compared with those without AF (13 vs. 0%, P = 0.012). In subgroup analysis, typical AFL patients with concomitant AF had a higher incidence of recurrent atrial tachyarrhythmia than those without it (53 vs. 14%, P = 0.006). Regarding patients without AF, the typical AFL group had a lower recurrence rate of atrial tachyarrhythmia than the atypical AFL group (14 vs. 40%, P = 0.043). Multivariate analysis showed that chronic kidney disease (CKD) and left atrial diameter (LAD) were independent predictors of recurrence. Conclusions: In our study cohort, concomitant AF was associated with recurrence of atrial tachyarrhythmia. CKD and LAD independently predicted recurrence after AFL ablation in patients who have undergone cardiac surgery for VHD.
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Affiliation(s)
- Ching-Yao Chou
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Division of Cardiology, Medical Center, Shin Kong Wu Ho Su Memorial Hospital, Taipei, Taiwan
| | - Fa-Po Chung
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hung-Yu Chang
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Cardiology, Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Li-Wei Lo
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Feng Hu
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Tze-Fan Chao
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jo-Nan Liao
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ta-Chuan Tuan
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chin-Yu Lin
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ting-Yung Chang
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chih-Min Liu
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Cheng-I Wu
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Sung-Hao Huang
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University Hospital, Yilan, Taiwan
| | - Chun-Chao Chen
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Han Cheng
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shin-Huei Liu
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Isaiah Carlos Lugtu
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Heart Institute, Chinese General Hospital and Medical Center, Manila, Philippines
| | - Ankit Jain
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - An-Ning Feng
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Cardiology, Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Shih-Lin Chang
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shih-Ann Chen
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
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9
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Zelnick LR, Shlipak MG, Soliman EZ, Anderson A, Christenson R, Lash J, Deo R, Rao P, Afshinnia F, Chen J, He J, Seliger S, Townsend R, Cohen DL, Go A, Bansal N. Prediction of Incident Atrial Fibrillation in Chronic Kidney Disease: The Chronic Renal Insufficiency Cohort Study. Clin J Am Soc Nephrol 2021; 16:1015-1024. [PMID: 34597264 PMCID: PMC8425618 DOI: 10.2215/cjn.01060121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 04/28/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Atrial fibrillation (AF) is common in CKD and associated with poor kidney and cardiovascular outcomes. Prediction models developed using novel methods may be useful to identify patients with CKD at highest risk of incident AF. We compared a previously published prediction model with models developed using machine learning methods in a CKD population. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We studied 2766 participants in the Chronic Renal Insufficiency Cohort study without prior AF with complete cardiac biomarker (N-terminal pro-B-type natriuretic peptide and high-sensitivity troponin T) and clinical data. We evaluated the utility of machine learning methods as well as a previously validated clinical prediction model (Cohorts for Heart and Aging Research in Genomic Epidemiology [CHARGE]-AF, which included 11 predictors, using original and re-estimated coefficients) to predict incident AF. Discriminatory ability of each model was assessed using the ten-fold cross-validated C-index; calibration was evaluated graphically and with the Grønnesby and Borgan test. RESULTS Mean (SD) age of participants was 57 (11) years, 55% were men, 38% were Black, and mean (SD) eGFR was 45 (15) ml/min per 1.73 m2; 259 incident AF events occurred during a median of 8 years of follow-up. The CHARGE-AF prediction equation using original and re-estimated coefficients had C-indices of 0.67 (95% confidence interval, 0.64 to 0.71) and 0.67 (95% confidence interval, 0.64 to 0.70), respectively. A likelihood-based boosting model using clinical variables only had a C-index of 0.67 (95% confidence interval, 0.64 to 0.70); adding N-terminal pro-B-type natriuretic peptide, high-sensitivity troponin T, or both biomarkers improved the C-index by 0.04, 0.01, and 0.04, respectively. In addition to N-terminal pro-B-type natriuretic peptide and high-sensitivity troponin T, the final model included age, non-Hispanic Black race/ethnicity, Hispanic race/ethnicity, cardiovascular disease, chronic obstructive pulmonary disease, myocardial infarction, peripheral vascular disease, use of angiotensin-converting enzyme inhibitor/angiotensin receptor blockers, calcium channel blockers, diuretics, height, and weight. CONCLUSIONS Using machine learning algorithms, a model that included 12 standard clinical variables and cardiac-specific biomarkers N-terminal pro-B-type natriuretic peptide and high-sensitivity troponin T had moderate discrimination for incident AF in a CKD population.
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Affiliation(s)
- Leila R. Zelnick
- Kidney Research Institute and Division of Nephrology, University of Washington, Seattle, Washington
| | - Michael G. Shlipak
- Department of Medicine, University of California, San Francisco, California
| | - Elsayed Z. Soliman
- Department of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Amanda Anderson
- Department of Epidemiology, Tulane University, New Orleans, Louisiana
| | | | - James Lash
- Division of Nephrology, University of Illinois–Chicago, Chicago, Illinois
| | - Rajat Deo
- Departments of Medicine and Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Panduranga Rao
- Department of Internal Medicine, Division of Nephrology, University of Michigan, Ann Arbor, Michigan
| | - Farsad Afshinnia
- Department of Medicine, Division of Nephrology, University of Michigan, Oakland, California
| | - Jing Chen
- Department of Medicine, Tulane University, New Orleans, Louisiana
| | - Jiang He
- Department of Epidemiology, Tulane University, New Orleans, Louisiana
| | - Stephen Seliger
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Raymond Townsend
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Debbie L. Cohen
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alan Go
- Division of Nephrology, University of Washington, Seattle, Washington
| | - Nisha Bansal
- Kidney Research Institute and Division of Nephrology, University of Washington, Seattle, Washington
- Kaiser Permanente Northern California, Oakland, California
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10
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Graves JM, Vallejo JA, Hamill CS, Wang D, Ahuja R, Patel S, Faul C, Wacker MJ. Fibroblast growth factor 23 (FGF23) induces ventricular arrhythmias and prolongs QTc interval in mice in an FGF receptor 4-dependent manner. Am J Physiol Heart Circ Physiol 2021; 320:H2283-H2294. [PMID: 33929896 DOI: 10.1152/ajpheart.00798.2020] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Fibroblast growth factor 23 (FGF23) is a phosphate regulating protein hormone released by osteocytes. FGF23 becomes markedly elevated in chronic kidney disease (CKD), for which the leading cause of death is cardiovascular disease, particularly sudden cardiac death. Previously, we found that FGF23 increases intracellular Ca2+ in cardiomyocytes and alters contractility in mouse ventricles ex vivo via FGF receptor 4 (FGFR4). In the present study, we demonstrate that FGF23 induces cardiac arrhythmias and prolongs QTc interval in mice, and we tested whether these effects are mediated through FGFR4. In isolated Langendorff perfused hearts, FGF23 perfusion increased mechanical arrhythmias in the form of premature ventricular beats (PVBs), and induced runs of ventricular tachycardia in 6 of 11 animals, which were attenuated with pretreatment of an anti-FGFR4 blocking antibody. Ex vivo ECG analysis of isolated intact hearts showed increased ventricular arrhythmias and QTc prolongation after FGF23 infusion compared with vehicle. In vivo, injection of FGF23 into the jugular vein led to the emergence of premature ventricular contractions (PVCs) in 5 out of 11 experiments. FGF23 also produced a significant lengthening effect upon QTc interval in vivo. In vivo FGFR4 blockade ameliorated the arrhythmogenic and QTc prolonging effects of FGF23. Finally, FGF23 increased cardiomyocyte Ca2+ levels in intact left ventricular muscle which was inhibited by FGR4 blockade. We conclude that FGF23/FGFR4 signaling in the heart may contribute to ventricular arrhythmogenesis and repolarization disturbances commonly observed in patients with CKD via Ca2+ overload and may be an important therapeutic target to reduce cardiac mortality in CKD.NEW & NOTEWORTHY Here we provide direct evidence that fibroblast growth factor 23 (FGF23), a phosphaturic hormone elevated in chronic kidney disease, is proarrhythmic. FGF23 acutely triggered ventricular arrhythmias and prolonged corrected QT interval (QTc) in isolated mouse hearts and in vivo. FGF23 also increased Ca2+ levels in ventricular muscle tissue. Blockade of the FGF receptor 4 signaling pathway using a monoclonal antibody ameliorated ventricular arrhythmias, QTc prolongation, and elevated ventricular Ca2+ induced by FGF23, and may represent a potential therapeutic target in chronic kidney disease.
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Affiliation(s)
- Jonah M Graves
- Department of Biomedical Sciences, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Julian A Vallejo
- Department of Biomedical Sciences, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Chelsea S Hamill
- Department of Biomedical Sciences, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Derek Wang
- Department of Biomedical Sciences, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Rohan Ahuja
- Department of Biomedical Sciences, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Shaan Patel
- Department of Biomedical Sciences, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Christian Faul
- Division of Nephrology, Department of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Michael J Wacker
- Department of Biomedical Sciences, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
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11
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Hannan M, Ansari S, Meza N, Anderson AH, Srivastava A, Waikar S, Charleston J, Weir MR, Taliercio J, Horwitz E, Saunders MR, Wolfrum K, Feldman HI, Lash JP, Ricardo AC. Risk Factors for CKD Progression: Overview of Findings from the CRIC Study. Clin J Am Soc Nephrol 2021; 16:648-659. [PMID: 33177074 PMCID: PMC8092061 DOI: 10.2215/cjn.07830520] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The Chronic Renal Insufficiency Cohort (CRIC) Study is an ongoing, multicenter, longitudinal study of nearly 5500 adults with CKD in the United States. Over the past 10 years, the CRIC Study has made significant contributions to the understanding of factors associated with CKD progression. This review summarizes findings from longitudinal studies evaluating risk factors associated with CKD progression in the CRIC Study, grouped into the following six thematic categories: (1) sociodemographic and economic (sex, race/ethnicity, and nephrology care); (2) behavioral (healthy lifestyle, diet, and sleep); (3) genetic (apoL1, genome-wide association study, and renin-angiotensin-aldosterone system pathway genes); (4) cardiovascular (atrial fibrillation, hypertension, and vascular stiffness); (5) metabolic (fibroblast growth factor 23 and urinary oxalate); and (6) novel factors (AKI and biomarkers of kidney injury). Additionally, we highlight areas where future research is needed, and opportunities for interdisciplinary collaboration.
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Affiliation(s)
- Mary Hannan
- Department of Medicine, University of Illinois, Chicago, Illinois
| | - Sajid Ansari
- Department of Medicine, University of Illinois, Chicago, Illinois
| | - Natalie Meza
- Department of Medicine, University of Illinois, Chicago, Illinois
| | - Amanda H. Anderson
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Anand Srivastava
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Division of Nephrology and Hypertension, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Sushrut Waikar
- Nephrology Section, Boston University Medical Center, Boston, Massachusetts
| | - Jeanne Charleston
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Matthew R. Weir
- Division of Nephrology, Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Jonathan Taliercio
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, Ohio
| | | | - Milda R. Saunders
- Department of Medicine, The University of Chicago, Chicago, Illinois
| | - Katherine Wolfrum
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Harold I. Feldman
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - James P. Lash
- Department of Medicine, University of Illinois, Chicago, Illinois
| | - Ana C. Ricardo
- Department of Medicine, University of Illinois, Chicago, Illinois
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12
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Vesga JI, Cepeda E, Pardo CE, Paez S, Sanchez R, Sanabria RM. Chronic Kidney Disease Progression and Transition Probabilities in a Large Preventive Cohort in Colombia. Int J Nephrol 2021; 2021:8866446. [PMID: 33868729 PMCID: PMC8032521 DOI: 10.1155/2021/8866446] [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] [Received: 09/17/2020] [Revised: 02/22/2021] [Accepted: 03/18/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Variability in chronic kidney disease (CKD) progression is a well-known phenomenon that underlines the importance of characterizing the said outcome in specific populations. Our objectives were to evaluate changes in the estimated glomerular filtration rate (eGFR) over time and determine the frequency of dialysis admission and factors associated with this outcome, to estimate the rate of program's loss-to-follow-up and the probability of transition between CKD stages over time. METHODS The study type was an observational analytic retrospective cohort in patients treated in a CKD prevention program in Bogota, Colombia, between January 1, 2009, and December 31, 2013, with follow-up until December 31, 2018. Adult participants of 18 years of age or older with diagnosed CKD stages G3 or G4 were enrolled into a prevention program. For each patient, the rate of progression of CKD in ml/min/1.73 m2/year was estimated using the ordinary least-squares method. Dialysis initiation and program's loss-to-follow-up rates were calculated. Heat maps were used to present probabilities of transitioning between various CKD stages over time. Survival model with competing risks was used to evaluate factors associated with dialysis initiation. RESULTS A total of 2752 patients met inclusion criteria and contributed with 14133 patient-years of follow-up and 200 dialysis initiation events, which represents a rate of 1.4 events per 100 patient-years (95% CI 1.2 to 1.6). The median change of the eGFR for the entire cohort was -0.47 ml/min/1.73 m2 per year, and in the diabetic population, it was -1.55 ml/min/1.73 m2 per year. The program's loss-to-follow-up rate was 2.6 events per 100 patient-years (95% CI 2.3 to 2.9). Probabilities of CKD stage transitions are presented in heat maps. Female sex, older age, baseline eGFR, and serum albumin were associated with lower risk of dialysis initiation while CKD etiology diabetes, cardiovascular disease history, systolic blood pressure, blood urea nitrogen, and LDL cholesterol were associated with a higher likelihood of dialysis initiation. CONCLUSIONS A CKD secondary prevention program's key indicator is reported here, such as dialysis initiation, progression rate, and program drop-out; CKD progression appears to be correlated with diabetic status and timing of referral into the preventive program.
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Affiliation(s)
| | - Edilberto Cepeda
- Statistics Department, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Campo E. Pardo
- Statistics Department, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Sergio Paez
- Statistics Department, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Ricardo Sanchez
- School of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
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13
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Kobalava ZD, Shavarov AA, Vatsik-Gorodetskaya MV. Direct Oral Anticoagulants in Patients with Atrial Fibrillation and Renal Dysfunction. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2021. [DOI: 10.20996/1819-6446-2021-02-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Atrial fibrillation and renal dysfunction often coexist, each disorder may predispose to the other and contribute to worsening prognosis. Both atrial fibrillation and chronic kidney disease are associated with increased risk of stroke and thromboembolic complications. Oral anticoagulation for stroke prevention is therefore recommended in patients with atrial fibrillation and decreased renal function. Each direct oral anticoagulant has unique pharmacologic properties of which clinician should be aware to optimally manage patients. The doses of direct oral anticoagulants require adjustment for renal function. There is debate regarding which equation, the Chronic Kidney Disease Epidemiology (CKD-EPI) equation vs. the Cockcroft-Gault equation, should be used to estimate glomerular filtration rate in patients with atrial fibrillation treated with direct oral anticoagulants. Our review tries to find arguments for benefit of direct oral anticoagulants in patients with renal dysfunction.
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Affiliation(s)
- Z. D. Kobalava
- Peoples Friendship University of Russia (RUDN University)
| | - A. A. Shavarov
- Peoples Friendship University of Russia (RUDN University)
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14
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Likhachev-Mishchenko OV, Kornienko AA, Kornienko NA, Khaisheva LA, Dyuzhikov AA, Shlyk SV. Asymptomatic Supraventricular Arrhythmias in Patients Undergoing Dialysis. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2021. [DOI: 10.20996/1819-6446-2021-02-13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Aim. Supraventricular arrhythmias (SVA) are associated with high morbidity and mortality. However, little attention is paid to this condition in patients undergoing hemodialysis. The aim of this study was to analyze the long-term relationship of intradialytic SVA, including asymptomatic arrhythmias, with adverse events in a cohort of patients undergoing hemodialysis.Material and methods. An observational prospective study was conducted in a group of patients on hemodialysis with a 10-year follow-up. The study involved 77 patients (42 men and 35 women; mean age 58±15 years) with sinus rhythm, then they were monitored for ECG for six consecutive hemodialysis sessions during recruitment.Results. Arterial hypertension was present in 68.8% of patients, diabetes mellitus in 29.9% of patients. SVA were reported in 38 patients (49.3%); they all had a short-term, asymptomatic character and were terminated independently. Age (hazard ratio [HR] 1.04 per year; 95% confidence interval [CI] 1.00-1.08) and an increase of the atrium (HR 4.29; 95%CI 1.30-14.09) were associated with supraventricular arrhythmia in multidimensional analysis. During an average follow-up of 40 months, 57 patients died, and cardiovascular diseases were the main cause of death (52.6%). Variables associated with all-cause mortality in the Cox model were age (HR 1.04 per year; 95%CI 1.00-1.08), C-reactive protein (HR 1.04 per 1 mg/l; 95%CI 1.00-1.08) and supraventricular arrhythmias (HR 3.21; 95%CI 1.29-7.96). Patients with supraventricular arrhythmias also had a higher risk of nonfatal cardiovascular events (HR 4.32; 95%CI 2.11-8.83) and symptomatic atrial fibrillation during observation (HR 17.19; 95%CI 2.03-145.15).Conclusions. Strong relationships have been established between the presence of supraventricular arrhythmias recorded during ECG during dialysis and symptomatic AF developing in the future. Patients with supraventricular arrhythmias had a larger right atrium. Age and supraventricular arrhythmias are the main variables associated with mortality in dialysis patients.
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15
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Gomez-Fernández P, Martín Santana A, Arjona Barrionuevo JDD. Oral anticoagulation in chronic kidney disease with atrial fibrillation. Nefrologia 2021; 41:137-153. [PMID: 36165375 DOI: 10.1016/j.nefroe.2021.04.005] [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: 02/03/2020] [Accepted: 08/11/2020] [Indexed: 06/16/2023] Open
Abstract
Chronic kidney disease (CKD) and atrial fibrillation (AF) frequently coexist, amplifying the risk of cardiovascular events and mortality. In patients with CKD stage 3 and non-valvular AF, direct oral anticoagulants (DOACs) have shown, compared to vitamin K antagonists (VKA), equal or greater efficacy in the prevention of stroke and systemic embolism, and greater safety. There are no randomizedtrials of the efficacy and safety of DOACs and VKA in advanced CKD. On the other hand, observational studies suggest that DOACs, compared to warfarin, are associated with a lower risk of acute kidney damage and generation/progression of CKD. This paper reviews the epidemiological and pathophysiological aspects of the CKD and AF association, the evidence of the efficacy and safety of warfarin and ACODs in various stages of CKD with AF as well as the comparison between warfarin and ACODs in efficacy and anticoagulant safety, and in its renal effects.
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Affiliation(s)
- Pablo Gomez-Fernández
- Unidad de Factores de Riesgo Vascular, Servicio de Nefrología, Hospital Universitario de Jerez, Jerez de la Frontera, Cádiz, Spain.
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16
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Whittemore H, Posen AK, Hellenbart EL, Groo V, Wenzler E, Tilton JJ. The Impact of Body Weight and Renal Function on the Risk of Bleeding With Direct Oral Anticoagulants in Atrial Fibrillation. Ann Pharmacother 2021; 55:1309-1317. [PMID: 33601914 DOI: 10.1177/1060028021995201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) increases the risk of stroke and direct oral anticoagulants (DOACs) are first-line agents for prevention. Gaps in the literature cause reluctance in prescribing DOACs for patients with renal dysfunction and/or extremes in body weight. OBJECTIVE To evaluate the impact body weight and renal function have on major and clinically relevant nonmajor (CRNM) bleeding events and ischemic strokes in AF patients receiving a DOAC. METHODS This retrospective cohort study included adults with nonvalvular atrial fibrillation (NVAF) or atrial flutter (AFL) receiving a DOAC ≥12 months. The primary outcome was a composite of major and CRNM bleeding events. Secondary outcomes included ischemic stroke and risk factors for bleeding events. RESULTS Of the 233 patients analyzed, 25 patients experienced a bleeding event. Patients who bled weighed 10 kg less (P = 0.043) than those who did not and had a higher HASBLED score (P = 0.003). Multivariate logistic regression identified weight (P = 0.048), serum creatinine (SCr; P = 0.027), and HASBLED score (P = 0.024) as the significant predictors for experiencing a bleed. Three patients experienced a stroke. CONCLUSION AND RELEVANCE This study demonstrates an association between higher baseline SCr, elevated HASBLED score, and lower weight, with an increased risk of bleeding in patients with NVAF or AFL receiving a DOAC. These findings add to prescribing considerations when initiating DOACs. Closer monitoring is advised for patients with significant renal dysfunction and/or low body weight, even with renal dose adjustments.
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Affiliation(s)
| | | | | | - Vicki Groo
- University of Illinois at Chicago, Chicago, IL, USA
| | - Eric Wenzler
- University of Illinois at Chicago, Chicago, IL, USA
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17
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Premužić V, Stevanović R, Radić P, Salvetti M, Lovrić-Benčić M, Jelaković A, Miličić D, Capak K, Agabiti-Rosei E, Jelaković B. Chronic kidney disease and cardiovascular mortality in patients with atrial fibrillation: European Society of Hypertension project - ESH A Fib. Medicine (Baltimore) 2021; 100:e23975. [PMID: 33466138 PMCID: PMC7808501 DOI: 10.1097/md.0000000000023975] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 11/30/2020] [Indexed: 01/05/2023] Open
Abstract
Our aim was to analyze characteristics of atrial fibrillation (AF) patients with chronic kidney disease (CKD) from the Croatian cohort of the ESH A Fib survey and to determine the association of estimated glomerular filtration rate (eGFR) with cardiovascular (CV) mortality after 24 months of follow-up.Consecutive sample of 301 patients with AF were enrolled in the period 2014 to 2018. Hypertension was defined as BP > 140/90 mm Hg and/or antihypertensive drugs treatment, CKD was defined as eGFR (CKD Epi) < 60 ml/min/1.73 m2 which was confirmed after 3 months.CKD was diagnosed in 45.2% of patients (13.3% in CKD stage > 3b). CKD patients were older than non-CKD and had significantly more frequent coronary heart disease, heart failure and valvular disease. CKD patients had significantly higher CHA2DS2-VASc score and more CKD than non-CKD patients had CHA2DS2-VASc > 2. Crude CV mortality rate per 1000 population at the end of the first year of the follow-up was significantly higher in CKD vs non-CKD group who had shorter mean survival time. CV mortality was independently associated with eGFR, male gender, CHA2DS2VASc and R2CHA2DS2VASc scores.Prevalence of CKD, particularly more advanced stages of CKD, is very high in patients with AF. Observed higher CV mortality and shorter mean survival time in CKD patients could be explained with higher CHA2DS2VASc score which is a consequence of clustering of all score components in CKD patients. However, eGFR was independently associated with CV mortality. In our cohort, R2CHA2DS2VASc score was not associated significantly more with CV mortality than CHA2DS2VASc score.
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Affiliation(s)
- Vedran Premužić
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Center Zagreb
- School of Medicine, Zagreb, Croatia
| | | | - Petra Radić
- University Hospital Center Sisters of Mercy, Zagreb, Croatia
| | | | - Martina Lovrić-Benčić
- Cardiology Clinic, University Hospital Center Zagreb
- School of Medicine, Zagreb, Croatia
| | - Ana Jelaković
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Center Zagreb
| | - Davor Miličić
- Cardiology Clinic, University Hospital Center Zagreb
- School of Medicine, Zagreb, Croatia
| | | | | | - Bojan Jelaković
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Center Zagreb
- School of Medicine, Zagreb, Croatia
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18
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Pavlova TV. An Elderly Comorbid Patient with Atrial Fibrillation: What is Important to Know and What Should be Considered When Prescribing Anticoagulants? RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2020. [DOI: 10.20996/1819-6446-2020-12-05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Anticoagulant therapy in elderly patients with atrial fibrillation and concomitant diseases is often the challenge for clinicians. The high risk of stroke is inherent in atrial fibrillation, and it increases when combined with coronary heart disease and chronic kidney disease. On the other hand, the comorbidity increases the risk of bleeding. Older age is also the risk factor of thrombotic and hemorrhagic complications. As a consequence, the choice of specific anticoagulant should be based on a solid evidences, obtained both from randomized clinical trials and from daily clinical practice. In the ROCKET AF trail the direct oral anticoagulant rivaroxaban showed a tendency to reduce the risk of thromboembolism by 20% compared with warfarin in the patients aged 75 years and older. The safety of rivaroxaban has been evaluated in the XANTUS POOLED program. According to the follow-up results for 12 months, more than 96% of patients didn't have any adverse event, and the number of patients with major bleeding was 1.5%. Several meta-analyzes reported a reduction of cardiovascular complications in patients treated by rivaroxaban. In the ROCKET AF trail, a “renal” dose of rivaroxaban (15 mg OD) was studied in patients with chronic kidney disease. The efficacy and safety of rivaroxaban were validated in this patients, and a simple algorithm for selecting the dose of this drug in patients with chronic kidney disease was provided.
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Parcha V, Patel N, Kalra R, Kim J, Gutiérrez OM, Arora G, Arora P. Incidence and Implications of Atrial Fibrillation/Flutter in Hypertension: Insights From the SPRINT Trial. Hypertension 2020; 75:1483-1490. [PMID: 32362231 DOI: 10.1161/hypertensionaha.120.14690] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
We evaluated the impact of intensive blood pressure control on the incidence of new-onset atrial fibrillation/flutter (AF) and the prognostic implications of preexisting and new-onset AF in SPRINT (Systolic Blood Pressure Intervention Trial) participants. New-onset AF was defined as occurrence of AF in 12-lead electrocardiograms after randomization in participants free of AF at baseline. Poisson regression modeling was used to calculate incident rates of new-onset AF. Multivariable-adjusted Cox proportional hazard models were used to evaluate the risk of adverse cardiovascular events (composite of myocardial infarction, non-myocardial infarction acute coronary syndrome, stroke, heart failure, or cardiovascular death). In 9327 participants, 8.45% had preexisting AF, and 1.65% had new-onset AF. The incidence of new-onset AF was 4.53 per 1000-person years, with similar rates in the standard and intensive treatment arms (4.95 versus 4.11 per 1000-person years; adjusted P=0.14). Participants with preexisting AF (adjusted hazard ratio, 1.83 [95% CI, 1.46-2.31]; P<0.001) and new-onset AF (adjusted hazard ratio, 2.45 [95% CI, 1.58-3.80]; P<0.001) had a greater risk for development of adverse cardiovascular events compared with those with no AF. Participants with preexisting AF who achieved blood pressure <120/80 mm Hg at 3 months continued have a poor prognosis (adjusted hazard ratio, 1.88 [95% CI, 1.32-2.70]; P=0.001) compared with those with no AF. Intensive blood pressure control does not diminish the incidence of new-onset AF in an older, high-risk, nondiabetic population. Both preexisting and new-onset AF have adverse prognostic implications. In participants with preexisting AF, residual cardiovascular risk is evident even with on-treatment blood pressure <120/80 mm Hg. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT01206062.
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Affiliation(s)
- Vibhu Parcha
- From the Division of Cardiovascular Disease (V.P., J.K., G.A., P.A.), University of Alabama at Birmingham, Birmingham
| | - Nirav Patel
- Department of Medicine (N.P.), University of Alabama at Birmingham, Birmingham
| | - Rajat Kalra
- Cardiovascular Division, University of Minnesota, Minneapolis (R.K.)
| | - Joonseok Kim
- From the Division of Cardiovascular Disease (V.P., J.K., G.A., P.A.), University of Alabama at Birmingham, Birmingham
| | - Orlando M Gutiérrez
- Division of Nephrology, Department of Medicine (O.M.G.), University of Alabama at Birmingham, Birmingham
- Department of Epidemiology (O.M.G.), University of Alabama at Birmingham, Birmingham
| | - Garima Arora
- From the Division of Cardiovascular Disease (V.P., J.K., G.A., P.A.), University of Alabama at Birmingham, Birmingham
| | - Pankaj Arora
- From the Division of Cardiovascular Disease (V.P., J.K., G.A., P.A.), University of Alabama at Birmingham, Birmingham
- Section of Cardiology, Birmingham Veterans Affairs Medical Center, AL (P.A.)
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20
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Ravera M, Bussalino E, Fusaro M, Di Lullo L, Aucella F, Paoletti E. Systematic DOACs oral anticoagulation in patients with atrial fibrillation and chronic kidney disease: the nephrologist's perspective. J Nephrol 2020; 33:483-495. [PMID: 32200488 DOI: 10.1007/s40620-020-00720-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 03/12/2020] [Indexed: 12/19/2022]
Abstract
Atrial fibrillation (AF) is highly prevalent among patients with chronic kidney disease (CKD), and also associated with unfavorable outcome. Anticoagulant therapy is the mainstep of management in such patients, aimed at reducing the high risk of systemic thromboembolism and especially of ischemic stroke, which is reportedly associated with increased mortality in CKD patients. Even though new direct oral anticoagulant agents (DOACs) proved to be effective in patients with non valvular chronic AF, and are therefore recommended by recent guidelines for their treatment, warfarin is currently used in more than one-half of subjects needing oral anticoagulation, and only 30% of them are converted from a vitamin K antagonist- to a DOAC-based regimen. The main reason for not prescribing DOACs is often a reduction in renal function, even if mild. Aim of this review was therefore to evaluate the impact of DOAC therapy in the setting of CKD, from a nephrological perspective, by comparing available evidence on the role of DOACs in patients with CKD and AF with that emerging from traditional warfarin-based therapy. Both the pathogenesis of AF in CKD, and available findings of renal, cardiovascular and bone effects of DOACs in CKD are discussed, leading to the conclusion that DOAC therapy should be considered as the first line therapy for non valvular AF in patients with mild and moderate reduction of renal function, and could also be adopted for patients with severe CKD not on hemodialysis treatment, whereas there is insufficient evidence for ESRD patients on dialysis.
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Affiliation(s)
- Maura Ravera
- Nephrology, Dialysis, and Transplantation, University of Genoa and Policlinico San Martino, Genoa, Italy.
| | - Elisabetta Bussalino
- Nephrology, Dialysis, and Transplantation, University of Genoa and Policlinico San Martino, Genoa, Italy
| | - Maria Fusaro
- National Research Council (CNR), Institute of Clinical Physiology (IFC), Pisa, Italy
- Department of Medicine, University of Padova, Padua, Italy
| | - Luca Di Lullo
- Department of Nephrology and Dialysis, Parodi-Delfino Hospital, Colleferro, Rome, Italy
| | - Filippo Aucella
- Nephrology and Dialysis Unit, IRCCS "Casa Sollievo della Sofferenza" Scientific Institute for Research and Health Care, San Giovanni Rotondo, Italy
| | - Ernesto Paoletti
- Nephrology, Dialysis, and Transplantation, University of Genoa and Policlinico San Martino, Genoa, Italy
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21
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Hu L, Xiong Q, Chen Z, Fu L, Hu J, Chen Q, Tu W, Xu C, Xu G, Li J, Hong K. Factors Associated with a Large Decline in Renal Function or Progression to Renal Insufficiency in Hospitalized Atrial Fibrillation Patients with Early-Stage CKD. Int Heart J 2020; 61:239-248. [PMID: 32173696 DOI: 10.1536/ihj.19-205] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Clinicians must consider renal function when administering anticoagulants for atrial fibrillation (AF). Determination of risk factors for renal function decline may enable identification of patients who require closer monitoring. We investigated the characteristics associated with renal function decline in patients with AF. The study cohort consisted of 631 AF patients who had at least one readmission during the follow-up period and stages 1-3 chronic kidney disease (CKD). The primary outcome measure was large renal function decline (≥30% decrease from baseline estimated glomerular filtration rate [eGFR]). The secondary outcome measure was a final eGFR < 60 mL/minute/1.73 m2 for those with a baseline eGFR above this level. The mean eGFR was 74.4 ± 18.5 mL/minute/1.73 m2, and the mean follow-up time was 30.2 ± 13.2 months. The primary outcome occurred in 155 patients (24.6%) and was associated with congestive heart failure (CHF), proteinuria, type of AF, and left atrial diameter (LAD) ≥ 45 mm. Among 478 patients with a baseline eGFR ≥ 60 mL/minute/1.73 m2, 137 (28.7%) progressed to renal failure (eGFR < 60 mL/minute/1.73 m2). A decreasing eGFR was associated with age ≥ 75 years, CHF, lower baseline eGFR, and LAD ≥ 45 mm. CHF, proteinuria, type of AF, and LAD ≥ 45 mm were associated with eGFR decline ≥ 30% in AF patients with CKD stages 1-3. Advanced age, CHF, lower baseline eGFR, and LAD ≥ 45 mm were associated with progression to renal insufficiency. These results should be considered when identifying patients who require more frequent monitoring of eGFR.
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Affiliation(s)
- Lili Hu
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University.,Department of Nephrology, The Second Affiliated Hospital of Nanchang University
| | - Qinmei Xiong
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University
| | - Zhiqing Chen
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University
| | - Linghua Fu
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University
| | - Jinzhu Hu
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University
| | - Qi Chen
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University
| | - Weiping Tu
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University
| | - Chengyun Xu
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University
| | - Gaosi Xu
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University
| | - Juxiang Li
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University
| | - Kui Hong
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University.,Jiangxi Key Laboratory of Molecular Medicine
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22
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Domek M, Li YG, Gumprecht J, Asaad N, Rashed W, Alsheikh-Ali A, Nabrdalik K, Gumprecht J, Zubaid M, Lip GY. One-year all-cause mortality risk among atrial fibrillation patients in Middle East with and without diabetes: The Gulf SAFE registry. Int J Cardiol 2020; 302:47-52. [DOI: 10.1016/j.ijcard.2019.12.061] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 12/08/2019] [Accepted: 12/29/2019] [Indexed: 12/17/2022]
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Wilson LE, Luo X, Li X, Mardekian J, Garcia Reeves AB, Skinner A. Clinical outcomes and treatment patterns among Medicare patients with nonvalvular atrial fibrillation (NVAF) and chronic kidney disease. PLoS One 2019; 14:e0225052. [PMID: 31725743 PMCID: PMC6855694 DOI: 10.1371/journal.pone.0225052] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 10/28/2019] [Indexed: 01/18/2023] Open
Abstract
Background Patients with nonvalvular atrial fibrillation (NVAF) and chronic kidney disease (CKD) have increased risk of adverse outcomes. This study evaluated treatment with oral anticoagulants and outcomes in elderly NVAF patients with CKD. Methods Retrospective observational cohort study of US Medicare fee-for-service patients aged ≥66 years with comorbid CKD (advanced: Stage 4 and higher; less advanced: Stages 1–3) and a new NVAF diagnoses from 2011–2013. All-cause mortality, stroke, major bleeding, and myocardial infarction rates were estimated for 1 year post-NVAF diagnosis. Associations between CKD stage and outcomes were evaluated with multivariate-adjusted Cox regression. We assessed oral anticoagulant (OAC) receipt within 90 days post-NVAF diagnosis and associations between OAC receipt and outcomes. Results There were 198,380 eligible patients (79,681 with advanced CKD). After adjustment for age, gender, and comorbidities, advanced CKD was associated with increased mortality (Stage 5 HR 1.47; 95% CI 1.42–1.52), MI (HR 1.48; 95% CI 1.33–1.64), stroke (HR 1.23; 95% CI 1.11–1.37) and major bleed (HR 1.44; 95% CI 1.36–1.53) risks. Among Medicare Part D enrollees who survived ≥90 days post-NVAF diagnosis, 65–71% received no OACs in the first 90 days. Those receiving warfarin (HR 0.73; 95% CI 0.71–0.75) or DOACs (HR 0.52; 95% CI 0.49–0.56) within the first 90 days had reduced mortality in the period 90 days to 1 year following NVAF diagnosis compared to those without. Conclusion Elderly NVAF patients with advanced CKD (Stage 4 or higher) had higher mortality risks and serious clinical outcomes than those with less advanced CKD (Stage 1–3). OAC use was low across all CKD stages, but was associated with a lower mortality risk than no OAC use in the first year post-NVAF diagnosis.
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Affiliation(s)
- Lauren E. Wilson
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, United States of America
- * E-mail:
| | - Xuemei Luo
- Pfizer, Inc., New York City, NY, United States of America
| | - Xiaoyan Li
- Bristol Myers-Squibb Company, New York City, NY, United States of America
| | - Jack Mardekian
- Pfizer, Inc., New York City, NY, United States of America
| | - Alessandra B. Garcia Reeves
- Bristol Myers-Squibb Company, New York City, NY, United States of America
- University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Asheley Skinner
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, United States of America
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24
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He W, Zhang H, Zhu W, Xue Z. Effect of anticoagulation therapy in older patients with chronic kidney disease and atrial fibrillation: A meta-analysis. Medicine (Baltimore) 2019; 98:e17628. [PMID: 31626146 PMCID: PMC6824694 DOI: 10.1097/md.0000000000017628] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The role of anticoagulation therapy for stroke prevention in older atrial fibrillation (AF) patients with chronic kidney disease (CKD) remains unclear. Therefore, we conducted a meta-analysis to explore the efficacy and safety of anticoagulation therapy in this population. METHODS The Cochrane Library, PubMed, and Embase databases were systematically searched for studies reporting the effect of anticoagulation therapy in older patients with AF and CKD. The risk ratios (RRs) and 95% confidence intervals (CIs) were regarded as the risk estimates. A random-effects model selected was to evaluate the treatment outcomes. The presentations were based on the Preferred Reporting Items for reporting systematic reviews and meta-analyses statement. RESULTS A total of 7 studies with 24,794 older patients with AF and CKD were included. The follow-up of the included studies ranged from 0.9 to 9.0 years. In older patients with no dialysis, compared with nonanticoagulants, anticoagulants reduced the risk of all-cause death (RR 0.66, 95% CI 0.54-0.79), but had comparable risks of ischemic stroke/transient ischemic attack (TIA, RR 0.91, 95% CI 0.46-1.79) and bleeding (RR 1.17, 95% CI 0.86-1.60). In older patients with dialysis, compared with nonanticoagulants, anticoagulants increased the risk of bleeding (RR 1.37, 95% CI 1.09-1.74), but had similar risks of ischemic stroke/TIA (RR 1.18, 95% CI 0.88-1.58) and death (RR 0.87, 95% CI 0.60-1.27). CONCLUSION Compared with nonanticoagulation, anticoagulation therapy is associated with a reduced risk of death in older AF patients with nondialysis, but an increased risk of bleeding in older patients with dialysis.
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Affiliation(s)
- Wenfeng He
- Jiangxi Key Laboratory of Molecular Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang of Jiangxi
| | - Hao Zhang
- Department of Cardiovascular Medicine, Xiangdong Hospital Hunan normal University, Liling of Hunan
| | - Wengen Zhu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou of Guangdong
| | - Zhengbiao Xue
- Department of Critial Care Medicine, The First Affiliated Hospital of Gannan Medical University, Ganzhou of Jiangxi 341000, China
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25
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Gallinoro E, D'Elia S, Prozzo D, Lioncino M, Natale F, Golino P, Cimmino G. Cognitive Function and Atrial Fibrillation: From the Strength of Relationship to the Dark Side of Prevention. Is There a Contribution from Sinus Rhythm Restoration and Maintenance? ACTA ACUST UNITED AC 2019; 55:medicina55090587. [PMID: 31540311 PMCID: PMC6780629 DOI: 10.3390/medicina55090587] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 09/07/2019] [Accepted: 09/10/2019] [Indexed: 12/12/2022]
Abstract
Atrial fibrillation (AF) is the most common chronic cardiac arrhythmia with an increasing prevalence over time mainly because of population aging. It is well established that the presence of AF increases the risk of stroke, heart failure, sudden death, and cardiovascular morbidity. In the last two decades several reports have shown an association between AF and cognitive function, ranging from impairment to dementia. Ischemic stroke linked to AF is a well-known risk factor and predictor of cognitive decline. In this clinical scenario, the risk of stroke might be reduced by oral anticoagulation. However, recent data suggest that AF may be a predictor of cognitive impairment and dementia also in the absence of stroke. Cerebral hypoperfusion, reduced brain volume, microbleeds, white matter hyperintensity, neuroinflammation, and genetic factors have been considered as potential mechanisms involved in the pathogenesis of AF-related cognitive dysfunction. However, a cause-effect relationship remains still controversial. Consequently, no therapeutic strategies are available to prevent AF-related cognitive decline in stroke-free patients. This review will analyze the potential mechanisms leading to cognitive dysfunction in AF patients and examine the available data on the impact of a sinus rhythm restoration and maintenance strategy in reducing the risk of cognitive decline.
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Affiliation(s)
- Emanuele Gallinoro
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy.
| | - Saverio D'Elia
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy.
| | - Dario Prozzo
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy.
| | - Michele Lioncino
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy.
| | - Francesco Natale
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy.
| | - Paolo Golino
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy.
| | - Giovanni Cimmino
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy.
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Effects of Prevalent and Incident Atrial Fibrillation on Renal Outcome, Cardiovascular Events, and Mortality in Patients with Chronic Kidney Disease. J Clin Med 2019; 8:jcm8091378. [PMID: 31484322 PMCID: PMC6780958 DOI: 10.3390/jcm8091378] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 08/18/2019] [Accepted: 09/01/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Little is known about how incident atrial fibrillation (AF) affects the clinical outcomes in chronic kidney disease (CKD) patients and whether there is a different influence between pre-existing and incident AF. METHODS Incident CKD patients from 2000 to 2013 were retrieved from the National Health Insurance Research Database (NHIRD) of Taiwan and they were classified as non-AF (n = 15,251), prevalent AF (n = 612), and incident AF (n = 588). The outcomes of interest were end-stage renal disease (ESRD) requiring dialysis, all-cause mortality, cardiovascular (CV) mortality, acute myocardial infarction (AMI), stroke or systemic thromboembolism. RESULTS Compared with CKD patients without AF, those with prevalent or incident AF were associated with higher adjusted rates of ESRD (hazard ratio (HR), 1.40; 95% confidence interval (CI), 1.32-1.48; HR, 2.91; 95% CI, 2.74-3.09, respectively), stroke or systemic thromboembolism (HR, 1.89; 95% CI, 1.77-2.03; HR, 1.67; 95% CI, 1.54-1.81, respectively), AMI (HR, 1.24; 95% CI, 1.09-1.41; HR, 1.99; 95% CI, 1.75-2.27, respectively), all-cause mortality (HR, 1.64; 95% CI, 1.56-1.72; HR, 2.17; 95% CI, 2.06-2.29, respectively), and CV mortality (HR, 2.95; 95% CI, 2.62-3.32; HR, 4.61; 95% CI, 4.09-5.20, respectively). Intriguingly, CKD patients with prevalent AF were associated with lower adjusted rates of ESRD, AMI, all-cause mortality, and CV mortality compared with those with incident AF. CONCLUSION Both incident and prevalent AF were independently associated with greater risks of AMI, all-cause mortality, CV mortality, ESRD, and stroke or systemic thromboembolism. Our findings are novel in that, compared with prevalent AF, incident AF possessed an even higher risk of some clinical consequences, including ESRD, all-cause mortality, CV mortality, and AMI.
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27
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Janus SE, Hajjari J, Al-Kindi S. High-sensitivity troponin and the risk of atrial fibrillation in chronic kidney disease: Results from the Chronic Renal Insufficiency Cohort Study. Heart Rhythm 2019; 17:190-194. [PMID: 31421237 DOI: 10.1016/j.hrthm.2019.08.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) are at an increased risk of atrial fibrillation (AF). There is a need for novel biomarkers to reliably and accurately predict AF in this population. High-sensitivity troponin (HsTP) allows the detection of low troponin concentrations. The utility of HsTP for evaluating the risk of AF in CKD has not been established. OBJECTIVE We sought to explore the association between HsTP and the risk of incident AF in CKD. METHODS The Chronic Renal Insufficiency Cohort is a prospective cohort of 3939 individuals with mild to moderate CKD. HsTP was measured at study enrollment. Patients with a history of AF were excluded. Patients were followed for new-onset AF, and the association between HsTP and incident AF was examined using the Cox regression model. RESULTS A total of 3217 participants were included. Over a median follow-up period of 7.1 years (interquartile range 5.0-8.4 years), 252 patients developed new-onset AF (12 events per 1000 person-years of follow-up). The incidence of new-onset AF was 2.46%, 7.06%, and 11.5% at 3, 6, and 9 years, respectively. Compared with the lowest quartile of HsTP, patients in the third quartile of HsTP (hazard ratio 2.40; 95% confidence interval 1.58-3.65; P < .001) and the fourth quartile of HsTP (hazard ratio 4.43; 95% confidence interval 2.98-6.59; P < .001) had a higher incidence of AF. CONCLUSION HsTP levels are associated with an increased risk of AF in patients with mild to moderate CKD. This association remains significant despite adjustment for traditional AF risk factors and chronic renal disease.
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Affiliation(s)
- Scott E Janus
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jamal Hajjari
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Sadeer Al-Kindi
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio.
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Lamprea-Montealegre JA, Zelnick LR, Shlipak MG, Floyd JS, Anderson AH, He J, Christenson R, Seliger SL, Soliman EZ, Deo R, Ky B, Feldman HI, Kusek JW, deFilippi CR, Wolf MS, Shafi T, Go AS, Bansal N. Cardiac Biomarkers and Risk of Atrial Fibrillation in Chronic Kidney Disease: The CRIC Study. J Am Heart Assoc 2019; 8:e012200. [PMID: 31379242 PMCID: PMC6761652 DOI: 10.1161/jaha.119.012200] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background We tested associations of cardiac biomarkers of myocardial stretch, injury, inflammation, and fibrosis with the risk of incident atrial fibrillation (AF) in a prospective study of chronic kidney disease patients. Methods and Results The study sample was 3053 participants with chronic kidney disease in the multicenter CRIC (Chronic Renal Insufficiency Cohort) study who were not identified as having AF at baseline. Cardiac biomarkers, measured at baseline, were NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide), high‐sensitivity troponin T, galectin‐3, growth differentiation factor‐15, and soluble ST‐2. Incident AF (“AF event”) was defined as a hospitalization for AF. During a median follow‐up of 8 years, 279 (9%) participants developed a new AF event. In adjusted models, higher baseline log‐transformed NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide) was associated with incident AF (adjusted hazard ratio [HR] per SD higher concentration: 2.11; 95% CI, 1.75, 2.55), as was log‐high‐sensitivity troponin T (HR 1.42; 95% CI, 1.20, 1.68). These associations showed a dose–response relationship in categorical analyses. Although log‐soluble ST‐2 was associated with AF risk in continuous models (HR per SD higher concentration 1.35; 95% CI, 1.16, 1.58), this association was not consistent in categorical analyses. Log‐galectin‐3 (HR 1.05; 95% CI, 0.91, 1.22) and log‐growth differentiation factor‐15 (HR 1.16; 95% CI, 0.96, 1.40) were not significantly associated with incident AF. Conclusions We found strong associations between higher NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide) and high‐sensitivity troponin T concentrations, and the risk of incident AF in a large cohort of participants with chronic kidney disease. Increased atrial myocardial stretch and myocardial cell injury may be implicated in the high burden of AF in patients with chronic kidney disease.
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Affiliation(s)
- Julio A Lamprea-Montealegre
- Kidney Research Institute Department of Medicine University of Washington Seattle WA.,Division of Cardiology Department of Medicine University of Washington Seattle WA
| | - Leila R Zelnick
- Kidney Research Institute Department of Medicine University of Washington Seattle WA.,Division of Nephrology Department of Medicine University of Washington Seattle WA
| | - Michael G Shlipak
- Department of Epidemiology, Biostatistics, and Medicine University of California San Francisco CA.,Department of General Internal Medicine San Francisco VA Medical Center San Francisco CA
| | - James S Floyd
- Division of General Internal Medicine Department of Medicine University of Washington Seattle WA
| | - Amanda H Anderson
- Translational Science Institute School of Public Health and Tropical Medicine Tulane University New Orleans LA
| | - Jiang He
- Translational Science Institute School of Public Health and Tropical Medicine Tulane University New Orleans LA
| | | | | | | | - Rajat Deo
- Departments of Medicine and Epidemiology and Biostatistics University of Pennsylvania Philadelphia PA
| | - Bonnie Ky
- Departments of Medicine and Epidemiology and Biostatistics University of Pennsylvania Philadelphia PA
| | - Harold I Feldman
- Departments of Medicine and Epidemiology and Biostatistics University of Pennsylvania Philadelphia PA
| | - John W Kusek
- Departments of Medicine and Epidemiology and Biostatistics University of Pennsylvania Philadelphia PA
| | | | - Myles S Wolf
- Department of Medicine Duke University Durham NC
| | - Tariq Shafi
- Department of Medicine Johns Hopkins University Baltimore MD
| | - Alan S Go
- Kaiser Permanente Northern California Oakland CA
| | - Nisha Bansal
- Division of Nephrology Department of Medicine University of Washington Seattle WA
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Batiushin MM. [The Nephrological Aspects of the Use of Rivaroxaban and Other Direct Peroral Anticoagulants in Non-Valvular Atrial Fibrillation]. KARDIOLOGIIA 2019; 59:60-69. [PMID: 31242842 DOI: 10.18087/cardio.2019.6.n516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 03/12/2019] [Indexed: 06/09/2023]
Abstract
Chronic kidney disease (CKD) is a powerful cardiovascular risk factor, its presence is accompanied by an increased risk of hospitalization for exacerbation of chronic heart failure (CHF), adverse outcomes in myocardial infarction, and cardiovascular mortality. Among the adverse events, an increased risk of atrial fibrillation (AF) should be noted. This article contains discussion of current approaches to the treatment of AF in patients with different stages of CKD, data on benefits of certain direct oral anticoagulants, as well as comparative characteristics of therapy with direct oral anticoagulants and warfarin. Pharmacokinetics and pharmacodynamics of direct oral anticoagulants, which determine the features of therapy in CKD, are also considered.
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Affiliation(s)
- M M Batiushin
- Federal state budgetary educational institution of higher education "Rostov state medical University" of the Ministry of health of the Russian Federation
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30
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Akoum N, Zelnick LR, de Boer IH, Hirsch IB, Trence D, Henry C, Robinson N, Bansal N. Rates of Cardiac Rhythm Abnormalities in Patients with CKD and Diabetes. Clin J Am Soc Nephrol 2019; 14:549-556. [PMID: 30890578 PMCID: PMC6450349 DOI: 10.2215/cjn.09420818] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 01/18/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Cardiac arrhythmias increase mortality and morbidity in CKD. We evaluated the rates of subclinical arrhythmias in a population with type 2 diabetes and patients with moderate to severe CKD who were not on dialysis. DESIGN, SETTING, PARTICIPANTS & MEASUREMENTS This is a prospective observational study, using continuous ambulatory cardiac monitors to determine the rate of atrial and ventricular arrhythmias, as well as conduction abnormalities in this group. RESULTS A total of 38 patients (34% women), with mean eGFR of 38±13 ml/min per 1.73 m2, underwent ambulatory cardiac monitoring for 11.2±3.9 days. The overall mean rate of any cardiac arrhythmia was 88.8 (95% confidence interval [95% CI], 27.1 to 184.6) episodes per person-year (PY). A history of cardiovascular disease was associated with a higher rate of detected arrhythmia (rate ratio, 5.87; 95% CI, 1.37 to 25.21; P<0.001). The most common arrhythmia was atrial fibrillation, which was observed in two participants with known atrial fibrillation and was a new diagnosis in four patients (11%), none of whom experienced symptoms. Overall, atrial fibrillation episodes occurred at a rate of 37.6 (95% CI, 2.4 to 112.3) per PY. Conduction abnormalities were found in eight patients (21%), a rate of 26.5 (95% CI, 4.2 to 65.5) per PY. Rates of ventricular arrhythmias were low (14.5 per PY; 95% CI, 4.3 to 32.0) and driven by premature ventricular contractions. CONCLUSIONS Cardiac rhythm abnormalities are common in patients with diabetes with moderate to severe CKD not requiring dialysis. Rates of atrial fibrillation are high and episodes are asymptomatic. Future studies are needed to determine the role of screening and upstream therapy of cardiac arrhythmias in this group.
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Affiliation(s)
| | | | - Ian H de Boer
- Kidney Research Institute.,Division of Nephrology, and
| | - Irl B Hirsch
- Kidney Research Institute.,Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle, Washington
| | - Dace Trence
- Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle, Washington
| | | | | | - Nisha Bansal
- Kidney Research Institute.,Division of Nephrology, and
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Tomaszuk-Kazberuk A, Nikas D, Lopatowska P, Młodawska E, Malyszko J, Bachorzewska-Gajewska H, Dobrzycki S, Sobkowicz B, Goudevenos I. Patients with Atrial Fibrillation and Chronic Kidney Disease More Often Undergo Angioplasty of Left Main Coronary Artery - a 867 Patient Study. Kidney Blood Press Res 2018; 43:1796-1805. [PMID: 30504712 DOI: 10.1159/000495637] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 11/21/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Several studies have implicated atrial fibrillation (AF) as a contributing factor in chronic kidney disease (CKD) and cardiovascular events. The prevalence of coronary artery disease (CAD) in patients with AF varies substantially from 17% to 46.5%. There are only few studies concerning renal function in population with AF undergoing coronary angiography. The aim of the present study was to assess which type of AF is dominant in CKD population scheduled for coronary angiography and if it can influence patients' outcome, the association between renal impairment and the type of coronary procedures in AF patients and the influence of renal function on in-hospital mortality. METHODS We retrospectively studied 867 patients with AF hospitalized due to coronary angiography in two year time. The cut off value of CKD was eGFR ≤ 60 ml/min./1.73m2 evaluated by CKD-EPI formula. RESULTS A total of 867 patients with AF (44% women; mean age 72±10 years) were included in the analysis. The mean eGFR was 44±11ml/min./1.73m2 in patients with CKD and 89±18 ml/min./1.73m2 in patients with preserved renal function. Patients with CKD and AF were older (p< 0.001), had more often diabetes (p=0.009), heart failure (p< 0.001) and anaemia (p< 0.001). Patients with CKD and AF had more often permanent type of AF (p< 0.001). In CKD patients CHA2DS2VASc score was 4.3±1.5 and HAS-BLED score was 2.0±1.2 and it was significantly higher as compared to population with preserved renal function (p< 0.001, p=0.02, respectively). The use of oral anticoagulation was less frequent in CKD group (p< 0.001) although these patients had higher CHA2DS2VASc score. Patients with AF and CKD were more often admitted due to myocardial infarction (STEMI or NSTEMI) (p=0.02, p< 0.001, respectively) and more often underwent percutaneous coronary intervention (PCI) (p=0.01). Among coronary arteries the percutaneous coronary intervention (PCI) of left main artery was done more frequently in CKD patients (p=0.01). Among CKD population in-hospital mortality was significantly higher in patients with eGFR < 30 ml/min (p< 0.001). CONCLUSION Patients with CKD had more often permanent type of AF. Percutaneous interventions of the left main coronary artery, the only elective procedures influencing patients' prognosis, were done more frequently in CKD patients with AF. In-hospital mortality was significantly higher in patients with severe renal impairment. Despite the higher risk of ischaemic stroke in CKD group the use of oral anticoagulation therapy was significantly less frequent and the patients were deprived of the confirmed benefits of such treatment.
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Affiliation(s)
| | - Dimitrios Nikas
- Cardiology Department, Ioannina University Hospital, Ioannina, Greece
| | - Paulina Lopatowska
- Department of Cardiology, Medical University in Bialystok, Bialystok, Poland
| | - Elzbieta Młodawska
- Department of Cardiology, Medical University in Bialystok, Bialystok, Poland
| | - Jolanta Malyszko
- Department of Nephrology, Dialysis and Internal Medicine, Warsaw Medical University, Warsaw, Poland
| | - Hanna Bachorzewska-Gajewska
- Department of Invasive Cardiology, Medical University in Bialystok, Bialystok, Poland.,Department of Clinical Medicine, Medical University in Bialystok, Bialystok, Poland
| | - Slawomir Dobrzycki
- Department of Invasive Cardiology, Medical University in Bialystok, Bialystok, Poland
| | - Bożena Sobkowicz
- Department of Cardiology, Medical University in Bialystok, Bialystok, Poland
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Which anticoagulants should be used for stroke prevention in non-valvular atrial fibrillation and severe chronic kidney disease? Curr Opin Nephrol Hypertens 2018; 27:420-425. [DOI: 10.1097/mnh.0000000000000443] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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33
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Bansal N, Xie D, Sha D, Appel LJ, Deo R, Feldman HI, He J, Jamerson K, Kusek JW, Messe S, Navaneethan SD, Rahman M, Ricardo AC, Soliman EZ, Townsend R, Go AS. Cardiovascular Events after New-Onset Atrial Fibrillation in Adults with CKD: Results from the Chronic Renal Insufficiency Cohort (CRIC) Study. J Am Soc Nephrol 2018; 29:2859-2869. [PMID: 30377231 DOI: 10.1681/asn.2018050514] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 09/03/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF), the most common sustained arrhythmia in CKD, is associated with poor clinical outcomes in both patients without CKD and patients with dialysis-treated ESRD. However, less is known about AF-associated outcomes in patients with CKD who do not require dialysis. METHODS To prospectively examine the association of new-onset AF with subsequent risks of cardiovascular disease events and death among adults with CKD, we studied participants enrolled in the Chronic Renal Insufficiency Cohort Study who did not have AF at baseline. Outcomes included heart failure, myocardial infarction, stroke, and death occurring after diagnosis of AF. We used Cox regression models and marginal structural models to examine the association of incident AF with subsequent risk of cardiovascular disease events and death, adjusting for patient characteristics, laboratory values, and medication use. RESULTS Among 3080 participants, 323 (10.5%) developed incident AF during a mean 6.1 years of follow-up. Compared with participants who did not develop AF, those who did had higher adjusted rates of heart failure (hazard ratio [HR], 5.17; 95% confidence interval [95% CI], 3.89 to 6.87), myocardial infarction (HR, 3.64; 95% CI, 2.50 to 5.31), stroke (HR, 2.66; 95% CI, 1.50 to 4.74), and death (HR, 3.30; 95% CI, 2.65 to 4.12). These associations remained robust with additional adjustment for biomarkers of inflammation, cardiac stress, and mineral metabolism; left ventricular mass; ejection fraction; and left atrial diameter. CONCLUSIONS Incident AF is independently associated with two- to five-fold increased rates of developing subsequent heart failure, myocardial infarction, stroke, or death in adults with CKD. These findings have important implications for cardiovascular risk reduction.
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Affiliation(s)
- Nisha Bansal
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington;
| | - Dawei Xie
- Departments of Medicine and Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daohang Sha
- Departments of Medicine and Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lawrence J Appel
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Rajat Deo
- Departments of Medicine and Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Harold I Feldman
- Departments of Medicine and Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jiang He
- Department of Medicine, Tulane University, New Orleans, Louisiana
| | - Kenneth Jamerson
- Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - John W Kusek
- National Institutes of Health, Bethesda, Maryland
| | - Steven Messe
- Departments of Medicine and Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Mahboob Rahman
- Department of Medicine, University Hospitals, Case Western Reserve University, Cleveland, Ohio
| | | | - Elsayed Z Soliman
- Department of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Raymond Townsend
- Departments of Medicine and Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alan S Go
- Kaiser Permanente Northern California, Oakland, California.,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California; and.,Department of Health Research and Policy, Stanford University, Stanford, California
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Mehta R, Cai X, Lee J, Scialla JJ, Bansal N, Sondheimer JH, Chen J, Hamm LL, Ricardo AC, Navaneethan SD, Deo R, Rahman M, Feldman HI, Go AS, Isakova T, Wolf M. Association of Fibroblast Growth Factor 23 With Atrial Fibrillation in Chronic Kidney Disease, From the Chronic Renal Insufficiency Cohort Study. JAMA Cardiol 2018; 1:548-56. [PMID: 27434583 DOI: 10.1001/jamacardio.2016.1445] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
IMPORTANCE Levels of fibroblast growth factor 23 (FGF23) are elevated in chronic kidney disease (CKD) and strongly associated with left ventricular hypertrophy, heart failure, and death. Whether FGF23 is an independent risk factor for atrial fibrillation in CKD is unknown. OBJECTIVE To investigate the association of FGF23 with atrial fibrillation in CKD. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study of 3876 individuals with mild to severe CKD who enrolled in the Chronic Renal Insufficiency Cohort Study between June 19, 2003, and September 3, 2008, and were followed up through March 31, 2013. EXPOSURES Baseline plasma FGF23 levels. MAIN OUTCOMES AND MEASURES Prevalent and incident atrial fibrillation. RESULTS The study cohort comprised 3876 participants. Their mean (SD) age was 57.7 (11.0) years, and 44.8% (1736 of 3876) were female. Elevated FGF23 levels were independently associated with increased odds of prevalent atrial fibrillation (n = 660) after adjustment for cardiovascular and CKD-specific factors (odds ratio of highest vs lowest FGF23 quartile, 2.30; 95% CI, 1.69-3.13; P < .001 for linear trend across quartiles). During a median follow-up of 7.6 years (interquartile range, 6.3-8.6 years), 247 of the 3216 participants who were at risk developed incident atrial fibrillation (11.9 events per 1000 person-years). In fully adjusted models, elevated FGF23 was independently associated with increased risk of incident atrial fibrillation after adjustment for demographic, cardiovascular, and CKD-specific factors, and other markers of mineral metabolism (hazard ratio of highest vs lowest FGF23 quartile, 1.59; 95% CI, 1.00-2.53; P = .02 for linear trend across quartiles). The results were unchanged when further adjusted for ejection fraction, but individual adjustments for left ventricular mass index, left atrial area, and interim heart failure events partially attenuated the association of elevated FGF23 with incident atrial fibrillation. CONCLUSIONS AND RELEVANCE Elevated FGF23 is independently associated with prevalent and incident atrial fibrillation in patients with mild to severe CKD. The effect may be partially mediated through a diastolic dysfunction pathway that includes left ventricular hypertrophy, atrial enlargement, and heart failure events.
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Affiliation(s)
- Rupal Mehta
- Division of Nephrology and Hypertension, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois2Center for Translational Metabolism and Health, Institute of Public Health and Medicine, Northwestern University Feinbe
| | - Xuan Cai
- Center for Translational Metabolism and Health, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jungwha Lee
- Center for Translational Metabolism and Health, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Julia J Scialla
- Division of Nephrology, Department of Medicine, Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Nisha Bansal
- Division of Nephrology, Department of Medicine, University of Washington, Seattle
| | - James H Sondheimer
- Division of Nephrology and Hypertension, Department of Medicine, Wayne State University School of Medicine, Detroit, Michigan
| | - Jing Chen
- Division of Nephrology and Hypertension, Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana
| | - L Lee Hamm
- Division of Nephrology and Hypertension, Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana
| | - Ana C Ricardo
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago
| | - Sankar D Navaneethan
- Division of Nephrology, Department of Medicine, Dan L. Duncan Institute of Clinical and Translational Research, Baylor College of Medicine, Houston, Texas
| | - Rajat Deo
- Division of Cardiology, Electrophysiology Section, Department of Medicine, University of Pennsylvania, Philadelphia
| | - Mahboob Rahman
- Division of Nephrology and Hypertension, Department of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Harold I Feldman
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia12Renal Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia
| | - Alan S Go
- Cardiovascular and Metabolic Conditions Section, Department of Medicine, Comprehensive Clinical Research Unit, Kaiser Permanente Northern California Division of Research, Oakland
| | - Tamara Isakova
- Division of Nephrology and Hypertension, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois2Center for Translational Metabolism and Health, Institute of Public Health and Medicine, Northwestern University Feinbe
| | - Myles Wolf
- Division of Nephrology and Hypertension, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois2Center for Translational Metabolism and Health, Institute of Public Health and Medicine, Northwestern University Feinbe
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Airy M, Chang TI, Ding VY, Goldstein BA, Bansal N, Niu J, Navaneethan SD, Turakhia MP, Winkelmayer WC. Risk profiles for acute health events after incident atrial fibrillation in patients with end-stage renal disease on hemodialysis. Nephrol Dial Transplant 2018; 33:1590-1597. [PMID: 29145634 DOI: 10.1093/ndt/gfx301] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 09/20/2017] [Indexed: 12/11/2022] Open
Abstract
Background Little is known about the cardiovascular risks of incident atrial fibrillation/flutter (AF) in patients with end-stage renal disease (ESRD) undergoing hemodialysis (HD). Methods We studied older US patients who newly initiated HD for ESRD (2006-11) and who had not previously been diagnosed with AF, stroke, myocardial infarction (MI) or hip fracture. We used Cox regression with AF as a time-varying covariate, adjusted for socio-demographic characteristics and comorbidities to estimate hazard ratios [HRs (95% confidence intervals)] for the events of ischemic stroke, MI and death. Hip fracture served as a negative control outcome. Results We identified 85 377 older patients (mean age: 76.5 years) who initiated HD; of these, 14.3% were subsequently diagnosed with AF (14.9% thereof as primary diagnosis) and 49.8% died during follow-up. Incident AF was associated with nine times higher adjusted mortality during the first 30 days [9.2 (8.8-9.6)], 5-fold higher mortality between 31 and 90 days [4.6 (4.3-4.8)] and double the mortality beyond 90 days from first AF diagnosis [2.2 (2.1-2.3)]. Incident AF was similarly associated with higher adjusted risk of ischemic stroke: 2.1 (1.6-2.7) during the first 30 days, 2.5 (2.0-3.0) between 31 and 90 days and 1.5 (1.3-1.7) beyond 90 days. Similar findings were obtained for MI. However, the risk of hip fracture was only marginally increased following AF diagnosis [≤30 days: 1.1 (0.7-1.6); 31-90 days: 1.4 (1.0-1.8); >90 days: 1.2 (1.1-1.4)]. All associations were attenuated and the association with hip fracture was null when incident AF was defined by a primary diagnosis code. Conclusions AF was strongly associated with increased risks of ischemic stroke, MI and death, with risks highest soon after AF diagnosis but extending beyond 90 days.
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Affiliation(s)
- Medha Airy
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Tara I Chang
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Victoria Y Ding
- Center for Biomedical Informatics Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Benjamin A Goldstein
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Nisha Bansal
- Kidney Research Institute, Division of Nephrology, University of Nephrology, Seattle, WA, USA
| | - Jingbo Niu
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Sankar D Navaneethan
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Mintu P Turakhia
- Cardiovascular Division, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA.,Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Airy M, Schold JD, Jolly SE, Arrigain S, Bansal N, Winkelmayer WC, Nally JV, Navaneethan SD. Cause-Specific Mortality in Patients with Chronic Kidney Disease and Atrial Fibrillation. Am J Nephrol 2018; 48:36-45. [PMID: 30048961 DOI: 10.1159/000491023] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 06/09/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is associated with death in patients with chronic kidney disease (CKD). We examined the associations between AF and cause-specific mortality in a large CKD population. METHODS We included 62,459 patients with estimated glomerular filtration rate 15-59 mL/min/1.73 m2 (6,639 patients with AF and 55,820 without AF) followed in a large health care system. Outcomes included overall and cause-specific deaths (a) cardiovascular; (b) malignancy; and (c) non-cardiovascular/non-malignancy causes. Cox regression models for overall mortality and separate competing risk models for each major cause of death category were used to evaluate their respective associations with AF. RESULTS During a median follow-up of 4.1 years, 19,094 patients died; cause of death was known for 18,854 patients. After multivariable adjustment (demographics, comorbidities, relevant laboratory data, medication use, and kidney function), AF was associated with 23% (95% CI 18-29%) higher risk of all-cause mortality, 45% (95% CI 31-61%) higher risk of cardiovascular mortality and 13% (95% CI 3-22%) lower risk of malignancy-related mortality. Exclusion of patients with malignancy yielded similar results except for a lack of association between AF and malignancy-related deaths. Results were consistent across various stages of CKD. CONCLUSIONS In a non-dialysis-dependent CKD population, the presence of AF was associated with higher all-cause and cardiovascular mortality. These data suggest that patients with both CKD and AF are at high cardiovascular risk, and thus clinical practice (or trials) should aim at reducing the overall excess cardiovascular mortality (not stroke alone) in patients with AF and CKD.
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Affiliation(s)
- Medha Airy
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jesse D Schold
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Stacey E Jolly
- Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Susana Arrigain
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nisha Bansal
- Kidney Research Institute, University of Washington, Seattle, Washington, USA
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Joseph V Nally
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sankar D Navaneethan
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
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37
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Turakhia MP, Blankestijn PJ, Carrero JJ, Clase CM, Deo R, Herzog CA, Kasner SE, Passman RS, Pecoits-Filho R, Reinecke H, Shroff GR, Zareba W, Cheung M, Wheeler DC, Winkelmayer WC, Wanner C. Chronic kidney disease and arrhythmias: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Eur Heart J 2018; 39:2314-2325. [PMID: 29522134 PMCID: PMC6012907 DOI: 10.1093/eurheartj/ehy060] [Citation(s) in RCA: 159] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 12/18/2017] [Accepted: 01/27/2018] [Indexed: 12/15/2022] Open
MESH Headings
- Arrhythmias, Cardiac/epidemiology
- Arrhythmias, Cardiac/therapy
- Atrial Fibrillation/complications
- Atrial Fibrillation/drug therapy
- Atrial Fibrillation/epidemiology
- Death, Sudden, Cardiac/prevention & control
- Defibrillators, Implantable
- Humans
- Hyperkalemia/epidemiology
- Hyperkalemia/metabolism
- Hypokalemia/epidemiology
- Hypokalemia/metabolism
- Inflammation
- Kidney Failure, Chronic/epidemiology
- Kidney Failure, Chronic/metabolism
- Kidney Failure, Chronic/therapy
- Oxidative Stress
- Potassium/metabolism
- Renal Dialysis
- Renal Insufficiency, Chronic/epidemiology
- Renal Insufficiency, Chronic/metabolism
- Renal Insufficiency, Chronic/therapy
- Risk Factors
- Stroke/etiology
- Stroke/prevention & control
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Affiliation(s)
- Mintu P Turakhia
- Stanford University School of Medicine, Veterans Affairs Palo Alto Health Care System, Miranda Ave, Palo Alto, CA, USA
| | - Peter J Blankestijn
- Department of Nephrology, room F03.220, University Medical Center, Utrecht, The Netherlands
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, Stockholm, Sweden
| | - Catherine M Clase
- Department of Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, St. Joseph’s Healthcare, Marian Wing, 3rd Floor, M333, 50 Charlton Ave. E, Hamilton, Ontario, Canada
| | - Rajat Deo
- Section of Electrophysiology, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, 9 Founders Cardiology, Philadelphia, PA, USA
| | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota and Chronic Disease Research Group, Minneapolis Medical Research Foundation, 914 S. 8th Street, S4.100, Minneapolis, MN, USA
| | - Scott E Kasner
- Department of Neurology, 3W Gates Bldg. Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, USA
| | - Rod S Passman
- Northwestern University Feinberg School of Medicine and the Bluhm Cardiovascular Institute, 201 E. Huron St. Chicago, IL, USA
| | - Roberto Pecoits-Filho
- School of Medicine, Pontificia Universidade Catolica do Paraná, Rua Imaculada Conceição Curitiba PR, Brazil
| | - Holger Reinecke
- Department für Kardiologie und Angiologie Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, Muenster, Germany
| | - Gautam R Shroff
- Division of Cardiology, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN, USA
| | - Wojciech Zareba
- Heart Research Follow-up Program, Cardiology Division, University of Rochester Medical Center, Saunders Research Building, 265 Crittenden Blvd. CU, Rochester, NY, USA
| | | | - David C Wheeler
- Centre for Nephrology, University College London, Rowland Hill Street, London, UK
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, ABBR R705, MS: 395, Houston, TX, USA
| | - Christoph Wanner
- Division of Nephrology, Department of Medicine, University Hospital of Würzburg, Oberduerrbacherstr. 6 Würzburg, Germany
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38
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Shroff GR, Stoecker R, Hart A. Non-Vitamin K-Dependent Oral Anticoagulants for Nonvalvular Atrial Fibrillation in Patients With CKD: Pragmatic Considerations for the Clinician. Am J Kidney Dis 2018; 72:717-727. [PMID: 29728318 DOI: 10.1053/j.ajkd.2018.02.360] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 02/22/2018] [Indexed: 01/27/2023]
Abstract
Management of atrial fibrillation (AF) in patients with advanced chronic kidney disease (CKD) poses a complex conundrum because of higher risks for both thromboembolic and bleeding complications compared to the general population. This makes it particularly important for clinicians to carefully weigh the risks versus benefits of anticoagulation therapy to determine the individualized net clinical benefit for every patient. During the past few years, 4 non-vitamin K-dependent oral anticoagulant (NOAC) agents have supplemented warfarin in the therapeutic armamentarium for the prevention of systemic thromboembolism in nonvalvular AF. However, the use of NOACs in CKD specifically mandates a nuanced understanding due to their varying dependence on renal clearance, with resultant safety implications related to either underdosing (thromboembolism) or excessive drug exposure (bleeding). This pragmatic review highlights unique considerations pertaining to accurate estimation and temporal monitoring of kidney function in the context of NOAC use with specific clinical deliberations and variables when determining whether an NOAC is appropriate for a patient with CKD. The dependence of NOACs on renal clearance and several troubling safety signals in the published literature suggest that it is vital for nephrologists to be active members of a multidisciplinary team caring for these high-risk patients with CKD and AF.
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Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Internal Medicine, Hennepin County Medical Center, Minneapolis, MN; University of Minnesota Medical School, Minneapolis, MN.
| | - Rachel Stoecker
- Department of Pharmacy, Hennepin County Medical Center, Minneapolis, MN
| | - Allyson Hart
- Division of Nephrology, Department of Internal Medicine, Hennepin County Medical Center, Minneapolis, MN; University of Minnesota Medical School, Minneapolis, MN
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Massicotte-Azarniouch D, Kuwornu JP, Carrero JJ, Lam NN, Molnar AO, Zimmerman D, McCallum MK, Garg AX, Sood MM. Incident Atrial Fibrillation and the Risk of Congestive Heart Failure, Myocardial Infarction, End-Stage Kidney Disease, and Mortality Among Patients With a Decreased Estimated GFR. Am J Kidney Dis 2018; 71:191-199. [DOI: 10.1053/j.ajkd.2017.08.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 08/09/2017] [Indexed: 11/11/2022]
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Bansal N, Zelnick LR, Alonso A, Benjamin EJ, de Boer IH, Deo R, Katz R, Kestenbaum B, Mathew J, Robinson-Cohen C, Sarnak MJ, Shlipak MG, Sotoodehnia N, Young B, Heckbert SR. eGFR and Albuminuria in Relation to Risk of Incident Atrial Fibrillation: A Meta-Analysis of the Jackson Heart Study, the Multi-Ethnic Study of Atherosclerosis, and the Cardiovascular Health Study. Clin J Am Soc Nephrol 2017; 12:1386-1398. [PMID: 28798221 PMCID: PMC5586568 DOI: 10.2215/cjn.01860217] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 05/15/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVES The incidence of atrial fibrillation is high in ESRD, but limited data are available on the incidence of atrial fibrillation across a broad range of kidney function. Thus, we examined the association of eGFR and urine albumin-to-creatinine ratio with risk of incident atrial fibrillation. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We meta-analyzed three prospective cohorts: the Jackson Heart Study, the Multi-Ethnic Study of Atherosclerosis, and the Cardiovascular Health Study. Cox regression models were performed examining the association of eGFR and urine albumin-to-creatinine ratio with incident atrial fibrillation adjusting for demographics and comorbidity. In additional analyses, we adjusted for measures of subclinical cardiovascular disease (by electrocardiogram and cardiac imaging) and interim heart failure and myocardial infarction events. RESULTS In the meta-analyzed study population of 16,769 participants without prevalent atrial fibrillation, across categories of decreasing eGFR (eGFR>90 [reference], 60-89, 45-59, 30-44, and <30 ml/min per 1.73 m2), there was a stepwise increase in the adjusted risk of incident atrial fibrillation: hazard ratios (95% confidence intervals) were 1.00, 1.09 (0.97 to 1.24), 1.17 (1.00 to 1.38), 1.59 (1.28 to 1.98), and 2.03 (1.40 to 2.96), respectively. There was a stepwise increase in the adjusted risk of incident atrial fibrillation across categories of increasing urine albumin-to-creatinine ratio (urine albumin-to-creatinine ratio <15 [reference], 15-29, 30-299, and ≥300 mg/g): hazard ratios (95% confidence intervals) were 1.00, 1.04 (0.83 to 1.30), 1.47 (1.20 to 1.79), and 1.76 (1.18 to 2.62), respectively. The associations were consistent after adjustment for subclinical cardiovascular disease measures and interim heart failure and myocardial infarction events. CONCLUSIONS In this meta-analysis of three cohorts, reduced eGFR and elevated urine albumin-to-creatinine ratio were significantly associated with greater risk of incident atrial fibrillation, highlighting the need for further studies to understand mechanisms linking kidney disease with atrial fibrillation.
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Affiliation(s)
- Nisha Bansal
- Division of Nephrology, Kidney Research Institute
| | | | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Emelia J. Benjamin
- Department of Medicine, Boston University School of Medicine and School of Public Health, Boston, Massachusetts
| | - Ian H. de Boer
- Division of Nephrology, Kidney Research Institute
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Rajat Deo
- Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ronit Katz
- Division of Nephrology, Kidney Research Institute
| | | | - Jehu Mathew
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Mark J. Sarnak
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts; and
| | - Michael G. Shlipak
- Kidney Health Research Collaborative, San Francisco Veterans Affairs Medical Center and University of California, San Francisco, California
| | | | - Bessie Young
- Division of Nephrology, Kidney Research Institute
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Susan R. Heckbert
- Cardiovascular Health Research Unit, and
- Department of Epidemiology, University of Washington, Seattle, Washington
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41
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Cho ME, Craven TE, Cheung AK, Glasser SP, Rahman M, Soliman EZ, Stafford RS, Johnson KC, Bates JT, Burgner A, Taylor AA, Tamariz L, Tang R, Beddhu S. The association between insulin resistance and atrial fibrillation: A cross-sectional analysis from SPRINT (Systolic Blood Pressure Intervention Trial). J Clin Hypertens (Greenwich) 2017; 19:1152-1161. [PMID: 28866864 DOI: 10.1111/jch.13062] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 06/01/2017] [Accepted: 06/04/2017] [Indexed: 01/12/2023]
Abstract
It is unclear whether metabolic syndrome (MetS) is associated with atrial fibrillation (AF) in an older population with greater cardiovascular risk, including those with chronic kidney disease. The authors investigated the association between MetS and AF in participants in SPRINT (Systolic Blood Pressure Intervention Trial). MetS was defined based on the Modified Third National Cholesterol Education Program. The baseline prevalence rate for MetS was 55%, while 8.2% of the participants had AF. In multivariate regression analyses, AF was not associated with presence of MetS in either chronic kidney disease or non-chronic kidney disease subgroups. Age, race, history of cardiovascular diseases, decreased triglycerides, decreased pulse pressure, and albuminuria remained significantly associated with AF risk. In contrast to the general population, MetS was not associated with AF in the older population with increased cardiovascular risk studied in SPRINT.
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Affiliation(s)
- Monique E Cho
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, UT, USA.,George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, USA
| | - Timothy E Craven
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Alfred K Cheung
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, UT, USA.,George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, USA.,Department of Nephrology, The Second Xiangya Hospital, Changsha, China
| | - Stephen P Glasser
- Department of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mahboob Rahman
- Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Elsayed Z Soliman
- Epidemiological Cardiology Research Center, Wake Forest School of Medicine, Winston Salem, NC, USA
| | | | - Karen C Johnson
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jeffrey T Bates
- Division of General Internal Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.,Baylor College of Medicine, Houston, TX, USA
| | - Anna Burgner
- Division of Nephrology and Hypertension, Vanderbilt University, Nashville, TN, USA
| | - Addison A Taylor
- Baylor College of Medicine, Houston, TX, USA.,Division of Hypertension and Clinical Pharmacology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Leonardo Tamariz
- Division of General Internal Medicine, University of Miami, Miami, FL, USA
| | - Rocky Tang
- Division of Cardiothoracic and Abdominal Transplant Surgery, Columbia University, New York, NY, USA
| | - Srinivasan Beddhu
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, UT, USA.,George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT, USA
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Abstract
Hyperkalemia is a potentially life-threatening electrolyte disorder appreciated with greater frequency in patients with renal disease, heart failure, and with use of certain medications such as renin angiotensin aldosterone inhibitors. The traditional views that hyperkalemia can be reliably diagnosed by electrocardiogram and that particular levels of hyperkalemia confer cardiotoxic risk have been challenged by several reports of patients with atypic presentations. Epidemiologic data demonstrate strong associations of morbidity and mortality in patients with hyperkalemia but these associations appear disconnected in certain patient populations and in differing clinical presentations. Physiologic adaptation, structural cardiac disease, medication use, and degree of concurrent illness might predispose certain patients presenting with hyperkalemia to a lower or higher threshold for toxicity. These factors are often overlooked; yet data suggest that the clinical context in which hyperkalemia develops is at least as important as the degree of hyperkalemia is in determining patient outcome. This review summarizes the clinical data linking hyperkalemia with poor outcomes and discusses how the efficacy of certain treatments might depend on the clinical presentation.
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Affiliation(s)
- John R Montford
- Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; .,Renal Section, Medicine Service, Veterans Affairs Eastern Colorado Health System, Denver, Colorado; and
| | - Stuart Linas
- Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado.,Division of Nephrology, Department of Medicine, Denver Health and Hospitals, Denver, Colorado
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43
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Impaired renal function is associated with recurrence after cryoballoon catheter ablation for paroxysmal atrial fibrillation: A potential effect of non-pulmonary vein foci. J Cardiol 2017; 69:3-10. [DOI: 10.1016/j.jjcc.2016.07.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Revised: 07/02/2016] [Accepted: 07/13/2016] [Indexed: 11/18/2022]
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Bossard M, Kreuzmann R, Hochgruber T, Krisai P, Zimmermann AJ, Aeschbacher S, Pumpol K, Kessel-Schaefer A, Stephan FP, Handschin N, Sticherling C, Osswald S, Kaufmann BA, Paré G, Kühne M, Conen D. Determinants of Left Atrial Volume in Patients with Atrial Fibrillation. PLoS One 2016; 11:e0164145. [PMID: 27701468 PMCID: PMC5049755 DOI: 10.1371/journal.pone.0164145] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 09/20/2016] [Indexed: 11/18/2022] Open
Abstract
Introduction Left atrial (LA) enlargement is an important risk factor for incident stroke and a key determinant for the success of rhythm control strategies in patients with atrial fibrillation (AF). However, factors associated with LA volume in AF patients remain poorly understood. Methods Patients with paroxysmal or persistent AF were enrolled in this study. Real time 3-D echocardiography was performed in all participants and analyzed offline in a standardized manner. We performed stepwise backward linear regression analyses using a broad set of clinical parameters to determine independent correlates for 3-D LA volume. Results We included 210 patients (70.9% male, mean age 61±11years). Paroxysmal and persistent AF were present in 95 (45%) and 115 (55%) patients, respectively. Overall, 115 (55%) had hypertension, 11 (5%) had diabetes, and 18 (9%) had ischemic heart disease. Mean indexed LA volume was 36±12ml/m2. In multivariable models, significant associations were found for female sex (β coefficient -10.51 (95% confidence interval (CI) -17.85;-3.16), p = 0.0053), undergoing cardioversion (β 11.95 (CI 5.15; 18.74), p = 0.0006), diabetes (β 14.23 (CI 2.36; 26.10), p = 0.019), body surface area (BSA) (β 34.21 (CI 19.30; 49.12), p<0.0001), glomerular filtration rate (β -0.21 (CI -0.36; -0.06), p = 0.0064) and plasma levels of NT-pro brain natriuretic peptide (NT-proBNP) (β 6.79 (CI 4.05; 9.52), p<0.0001), but not age (p = 0.59) or hypertension (p = 0.42). Our final model explained 52% of the LA volume variability. Conclusions In patients with AF, the most important correlates with LA volume are sex, BSA, diabetes, renal function and NT-proBNP, but not age or hypertension. These results may help to refine rhythm control strategies in AF patients.
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Affiliation(s)
- Matthias Bossard
- Division of Cardiology, Hamilton General Hospital, Hamilton Health Sciences, McMaster University, 237 Barton Street East, Hamilton, ON, L8L 2X2, Canada.,Population Health Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, McMaster University, 237 Barton Street East, Hamilton, ON, L8L 2X2, Canada.,Cardiology Division, Department of Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital Basel, Spitalstrasse 2, 4031, Basel, Switzerland
| | - Rahel Kreuzmann
- Cardiovascular Research Institute Basel, University Hospital Basel, Spitalstrasse 2, 4031, Basel, Switzerland.,Division of Internal Medicine, Department of Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Thomas Hochgruber
- Cardiovascular Research Institute Basel, University Hospital Basel, Spitalstrasse 2, 4031, Basel, Switzerland.,Division of Internal Medicine, Department of Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Philipp Krisai
- Cardiovascular Research Institute Basel, University Hospital Basel, Spitalstrasse 2, 4031, Basel, Switzerland.,Division of Internal Medicine, Department of Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Andreas J Zimmermann
- Cardiovascular Research Institute Basel, University Hospital Basel, Spitalstrasse 2, 4031, Basel, Switzerland.,Division of Internal Medicine, Department of Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Stefanie Aeschbacher
- Cardiovascular Research Institute Basel, University Hospital Basel, Spitalstrasse 2, 4031, Basel, Switzerland.,Division of Internal Medicine, Department of Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Katrin Pumpol
- Cardiovascular Research Institute Basel, University Hospital Basel, Spitalstrasse 2, 4031, Basel, Switzerland.,Division of Internal Medicine, Department of Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Arnheid Kessel-Schaefer
- Cardiology Division, Department of Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital Basel, Spitalstrasse 2, 4031, Basel, Switzerland
| | - Frank-Peter Stephan
- Cardiology Division, Department of Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital Basel, Spitalstrasse 2, 4031, Basel, Switzerland
| | - Nadja Handschin
- Cardiovascular Research Institute Basel, University Hospital Basel, Spitalstrasse 2, 4031, Basel, Switzerland
| | - Christian Sticherling
- Cardiology Division, Department of Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital Basel, Spitalstrasse 2, 4031, Basel, Switzerland
| | - Stefan Osswald
- Cardiology Division, Department of Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital Basel, Spitalstrasse 2, 4031, Basel, Switzerland
| | - Beat A Kaufmann
- Cardiology Division, Department of Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital Basel, Spitalstrasse 2, 4031, Basel, Switzerland
| | - Guillaume Paré
- Population Health Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, McMaster University, 237 Barton Street East, Hamilton, ON, L8L 2X2, Canada.,Department of Pathology and Molecular Medicine, McMaster University, Michael G. DeGroote School of Medicine, 1280 Main Street West, Hamilton ON, L8S 4K1, Canada
| | - Michael Kühne
- Cardiology Division, Department of Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital Basel, Spitalstrasse 2, 4031, Basel, Switzerland
| | - David Conen
- Cardiology Division, Department of Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital Basel, Spitalstrasse 2, 4031, Basel, Switzerland.,Division of Internal Medicine, Department of Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
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Voroneanu L, Ortiz A, Nistor I, Covic A. Atrial fibrillation in chronic kidney disease. Eur J Intern Med 2016; 33:3-13. [PMID: 27155803 DOI: 10.1016/j.ejim.2016.04.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 04/07/2016] [Accepted: 04/09/2016] [Indexed: 02/02/2023]
Affiliation(s)
- Luminita Voroneanu
- Nephrology Department, Dialysis and Renal Transplant Center, "C.I. Parhon" University Hospital, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania.
| | - Alberto Ortiz
- Nephrology and Hypertension Department, IIS-Fundacion Jimenez Diaz and School of Medicine, Madrid, Spain
| | - Ionut Nistor
- Nephrology Department, Dialysis and Renal Transplant Center, "C.I. Parhon" University Hospital, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania
| | - Adrian Covic
- Nephrology Department, Dialysis and Renal Transplant Center, "C.I. Parhon" University Hospital, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania
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Lau YC, Proietti M, Guiducci E, Blann AD, Lip GY. Atrial Fibrillation and Thromboembolism in Patients With Chronic Kidney Disease. J Am Coll Cardiol 2016; 68:1452-1464. [DOI: 10.1016/j.jacc.2016.06.057] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 06/14/2016] [Indexed: 02/06/2023]
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Bansal N, Xie D, Tao K, Chen J, Deo R, Horwitz E, Hsu CY, Kallem RK, Keane MG, Lora CM, Raj D, Soliman EZ, Strauss L, Wolf M, Go AS. Atrial Fibrillation and Risk of ESRD in Adults with CKD. Clin J Am Soc Nephrol 2016; 11:1189-1196. [PMID: 27073197 PMCID: PMC4934846 DOI: 10.2215/cjn.10921015] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 03/08/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Atrial fibrillation frequently complicates CKD and is associated with adverse outcomes. Progression to ESRD is a major complication of CKD, but the link with atrial fibrillation has not been fully delineated. In this study, we examined the association of incident atrial fibrillation with the risk of ESRD in patients with CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We studied participants in the prospective Chronic Renal Insufficiency Cohort Study without atrial fibrillation at entry. Incident atrial fibrillation was identified by study visit ECGs, self-report, and hospital discharge diagnostic codes, with confirmation by physician adjudication. ESRD through 2012 was ascertained by participant self-report, medical records, and linkage to the US Renal Data System. Data on potential confounders were obtained from self-report, study visits, and laboratory tests. Marginal structural models were used to study the potential association of incident atrial fibrillation with risk of ESRD after adjustment for time-dependent confounding. RESULTS Among 3091 participants, 172 (5.6%) developed incident atrial fibrillation during follow-up. During mean follow-up of 5.9 years, 43 patients had ESRD that occurred after development of incident atrial fibrillation (11.8/100 person-years) compared with 581 patients without incident atrial fibrillation (3.4/100 person-years). In marginal structural models with inverse probability weighting, incident atrial fibrillation was associated with a substantially higher rate of ESRD (hazard ratio, 3.2; 95% confidence interval, 1.9 to 5.2). This association was consistent across important subgroups by age, sex, race, diabetes status, and baseline eGFR. CONCLUSIONS Incident atrial fibrillation was associated with higher risk of developing ESRD in CKD. Additional study is needed to identify potentially modifiable pathways through which atrial fibrillation was associated with a higher risk of progression to ESRD. More aggressive monitoring and treatment of patients with CKD and atrial fibrillation may improve outcomes in this high-risk population.
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Affiliation(s)
- Nisha Bansal
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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48
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Dad T, Weiner DE. Stroke and Chronic Kidney Disease: Epidemiology, Pathogenesis, and Management Across Kidney Disease Stages. Semin Nephrol 2016; 35:311-22. [PMID: 26355250 DOI: 10.1016/j.semnephrol.2015.06.003] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Cerebrovascular disease and stroke are very common at all stages of chronic kidney disease (CKD), likely representing both shared risk factors as well as synergy among risk factors. More subtle ischemic brain lesions may be particularly common in the CKD population, with subtle manifestations including cognitive impairment. For individuals with nondialysis CKD, the prevention, approach to, diagnosis, and management of stroke is similar to the general, non-CKD population. For individuals with end-stage renal disease, far less is known regarding strategies to prevent stroke. Stroke prophylaxis using warfarin in dialysis patients with atrial fibrillation in particular remains of uncertain benefit. End-stage renal disease patients can be managed aggressively in the setting of acute stroke. Outcomes after stroke at all stages of CKD are poor, and improving these outcomes should be the subject of future clinical trials.
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Affiliation(s)
- Taimur Dad
- Division of Nephrology, Tufts Medical Center, Boston, MA
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50
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Epidemiologic insights on the role of fibroblast growth factor 23 in cardiovascular disease. Curr Opin Nephrol Hypertens 2016; 24:260-7. [PMID: 26066475 DOI: 10.1097/mnh.0000000000000123] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE OF REVIEW Fibroblast growth factor 23 (FGF23) regulates phosphate and vitamin D homeostasis and rises as kidney function declines. Animal studies have demonstrated direct and indirect effects of FGF23 that may promote heart disease. Herein, we review the recent epidemiologic literature evaluating the relationship between FGF23 and cardiovascular disease. RECENT FINDINGS In observational prospective studies, higher FGF23 associates with a greater risk of incident cardiovascular disease including ischemic heart disease, stroke, heart failure, and atrial fibrillation. These studies establish a temporal sequence of events over long-term follow-up that suggest a possible role of FGF23 in cardiovascular disease pathogenesis. In most studies, risk is generally graded; however, in the largest study to date, higher FGF23 within the low-normal range was not associated with higher risk. In several recent studies higher FGF23 associated more strongly with the risk of congestive heart failure compared with atherosclerotic events, a finding consistent with surrogate endpoints and animal experiments. Currently, the utility of FGF23 as a predictive biomarker of cardiovascular risk is not established, and interventions to reduce FGF23 need to be studied to confirm its possible pathophysiologic role. SUMMARY Higher FGF23 is associated with the subsequent development of cardiovascular disease, and perhaps most notably heart failure, in a growing number of studies. These findings bolster ongoing efforts to lower FGF23 using strategies to reduce phosphate intake and absorption.
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