Effects of Prevalent and Incident Atrial Fibrillation on Renal Outcome, Cardiovascular Events, and Mortality in Patients with Chronic Kidney Disease

A review of the use of propensity score methods with multiple treatment groups in the general internal medicine literature

BACKGROUND

Propensity score (PS) methods with two treatment groups (e.g., treated vs. control) is a well-established technique for reducing the effects of confounding in nonrandomized studies. However, researchers are often interested in comparing multiple interventions. PS methods have been modified to incorporate multiple exposures. We described available techniques for PS methods in multicategory exposures (≥3 groups) and examined their use in the medical literature.

METHODS

A comprehensive search was conducted for studies published in PubMed, Embase, Google Scholar, and Web of Science until February 27, 2023. We included studies using PS methods for multiple groups in general internal medicine research.

RESULTS

The literature search yielded 4088 studies (2616 from PubMed, 86 from Embase, 85 from Google Scholar, 1671 from Web of Science, five from other sources). In total, 264 studies using PS method for multiple groups were identified; 61 studies were on general internal medicine topics and included. The most commonly used method was that of McCaffrey et al., which was used in 26 studies (43%), where the Toolkit for Weighting and Analysis of Nonequivalent Groups (TWANG) method and corresponding inverse probabilities of treatment weights were estimated via generalized boosted models. The next most commonly used method was pairwise propensity-matched comparisons, which was used in 20 studies (33%). The method by Imbens et al. using a generalized propensity score was implemented in six studies (10%). Four studies (7%) used a conditional probability of being in a particular group given a set of observed baseline covariates where a multiple propensity score was estimated using a non-parsimonious multinomial logistic regression model. Four studies (7%) used a technique that estimates generalized propensity scores and then creates 1:1:1 matched sets, and one study (2%) used the matching weight method.

CONCLUSIONS

Many propensity score methods for multiple groups have been adopted in the literature. The TWANG method is the most commonly used method in the general medical literature.

Revisiting risk prediction tools for death and end-stage renal disease in older patients with advanced chronic kidney disease: a prospective study

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.

[Atrial fibrillation-Syndromic phenotype in HFpEF or primary disease?]

Atrial fibrillation and heart failure with preserved left ventricular (LV) ejection fraction (HFpEF) are of high importance in cardiology due to the increasing number of cases. Both diseases can mutually affect each other and important cardiovascular risk factors, e.g. arterial hypertension, diabetes mellitus, obesity and chronic renal insufficiency can be observed with increasing frequency. Currently proven treatment concepts for patients with heart failure and reduced ejection fraction (HFrEF) do not appear to have a comparable prognostic or symptomatic benefit for patients with HFpEF. In addition, there are indications that de novo manifestation of atrial fibrillation in HFpEF patients has been linked to reduced survival. Also, heart and kidney function are negatively affected by atrial fibrillation. Retrospective analyses of patients with HFpEF and atrial fibrillation who had been treated by pulmonary vein isolation could show that interventional treatment of the atrial fibrillation led to an improvement in the New York Heart Association (NYHA) stage and diastolic function. Currently running prospective randomized clinical trials, such as the AMPERE study including patients with HFpEF and atrial fibrillation undergoing pulmonary vein isolation, will hopefully provide reliable prospective randomized data and possibly show an improved symptom control and perhaps also prognostically relevant treatment for HFpEF patients with atrial fibrillation.

Interatrial block, P terminal force or fragmented QRS do not predict new-onset atrial fibrillation in patients with severe chronic kidney disease

Background

The prevalence of left atrial enlargement (LAE) and fragmented QRS (fQRS) diagnosed using ECG criteria in patients with severe chronic kidney disease (CKD) is unknown. Furthermore, there is limited data on predicting new-onset atrial fibrillation (AF) with LAE or fQRS in this patient group.

Methods

We enrolled 165 consecutive non-dialysis patients with CKD stage 4–5 without prior AF diagnosis between 2013 and 2017 in a prospective follow-up cohort study. LAE was defined as total P-wave duration ≥120 ms in lead II ± > 1 biphasic P-waves in leads II, III or aVF; or duration of terminal negative portion of P-wave > 40 ms or depth of terminal negative portion of P-wave > 1 mm in lead V₁ from a baseline ECG, respectively. fQRS was defined as the presence of a notched R or S wave or the presence of ≥1 additional R waves (R’) or; in the presence of a wide QRS complex (> 120 ms), > 2 notches in R or S waves in two contiguous leads corresponding to a myocardial region, respectively.

Results

Mean age of the patients was 59 (SD 14) years, 56/165 (33.9%) were female and the mean estimated glomerular filtration rate was 12.8 ml/min/1.73m². Altogether 29/165 (17.6%) patients were observed with new-onset AF within median follow-up of 3 [IQR 3, range 2–6] years. At baseline, 137/165 (83.0%) and 144/165 (87.3%) patients were observed with LAE and fQRS, respectively. Furthermore, LAE and fQRS co-existed in 121/165 (73.3%) patients. Neither findings were associated with the risk of new-onset AF within follow-up.

Conclusion

The prevalence of LAE and fQRS at baseline in this study on CKD stage 4–5 patients not on dialysis was very high. However, LAE or fQRS failed to predict occurrence of new-onset AF in these patients.

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

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

Chronic Kidney Disease Has a Graded Association with Death and Cardiovascular Outcomes in Stable Coronary Artery Disease: An Analysis of 21,911 Patients from the CLARIFY Registry

: Chronic kidney disease (CKD) is associated with an increased cardiovascular risk in a broad spectrum of populations. However, the risk associated with a reduced estimated glomerular filtration rate (eGFR) in patients with stable coronary artery disease receiving standard care in the modern era, independently of baseline cardiovascular disease, risk factors, and comorbidities, remains unclear. We analyzed data from 21,911 patients with stable coronary artery disease, enrolled in 45 countries between November 2009 and July 2010 in the CLARIFY registry. Patients with abnormal renal function were older, with more comorbidities, and received slightly lower-although overall high-rates of evidence-based secondary prevention therapies than patients with normal renal function. The event rate of patients with CKD stage 3b or more (eGFR <45 mL/min/1.73 m2) was much higher than that associated with any comorbid condition. In a multivariable adjusted Cox proportional hazards model, lower eGFR was independently associated with a graded increased risk of cardiovascular mortality, with adjusted HRs (95% CI) of 0.98 (0.81-1.18), 1.31 (1.05-1.63), 1.77 (1.38-2.27), and 3.12 (2.25-4.33) for eGFR 60-89, 45-59, 30-44, and <30 mL/min/1.73 m2, compared with eGFR ≥90 mL/min/1.73 m2. A strong graded independent relationship exists between the degree of CKD and cardiovascular mortality in this large cohort of patients with chronic coronary artery disease, despite high rates of secondary prevention therapies. Among clinical risk factors and comorbid conditions, CKD stage 3b or more is associated with the highest cardiovascular mortality.