Influence of atrial fibrillation on the morbido-mortality of patients on hemodialysis

doi:10.1067/mhj.2000.111111

American Heart Journal

Volume 140, Issue 6, December 2000, Pages 886-890

https://doi.org/10.1067/mhj.2000.111111 Get rights and content

Abstract

Background The consequences of atrial fibrillation (AF) on morbido-mortality of patients on hemodialysis have not been fully explored. The objective of this study was to determine the prevalence of AF in patients on hemodialysis and to evaluate its influence on the development of thromboembolic phenomena (TEP). Methods The incidence of AF in 190 patients in our hemodialysis program was assessed, and the patients were followed up for 1 year. Pertinent demographic and biochemical parameters were entered into univariate and multivariate statistical analyses to evaluate associations with overall mortality and TEP such as cerebrovascular accident, transitory ischemic accident, or peripheral embolism. Results In 13.6% of patients, AF was found; 9.4% of these were of the permanent type. In the multivariate analysis, only increased age was associated with a higher probability of having arrhythmia (odds ratio, 1.10; 95% confidence interval, 1.03-1.17; P =.003). During follow-up, 23% of the patients with AF died compared with 6% of those in sinus rhythm (P <.05), although AF did not appear to be an independent predictive factor for death. Thirty-five percent of the patients with AF and 4% with sinus rhythm had TEP (P <.01). In the multivariate analysis, AF was identified as the only independent predictor for TEP (odds ratio, 8; 95% CI, 2.3-27; P =.0008). Conclusions AF is a frequent arrhythmia in patients on hemodialysis, and approximately 1 in 3 hemodialysis patients with AF had thromboembolic complications within 1 year of follow-up. These findings suggest that the consensus contraindication of prophylactic anticoagulation therapy for this group of patients may need to be redefined. (Am Heart J 2000;140:886-90.)

Section snippets

Methods

The incidence of AF in a cross section of 190 patients with chronic renal insufficiency on the hemodialysis program in our hospital was determined. The only inclusion criteria were that the patients should have been on hemodialysis for >3 months and should not have had a diagnosis of rheumatic valvular cardiopathy.

The patients were classified as having arrhythmia when this was clearly of the permanent type or, when intermittent, the episodes were repeated, prolonged, and refractory to

Results

Of the 190 patients, 26 (13.6%) had atrial fibrillation; of these, 18 (9.4%) were the permanent type of AF and 8 (4.2%) were the recurrent, persistent type. Table I summarizes the characteristics of the patients.

. Clinical characteristics of study patients (n = 190)

Characteristic	n (% of study group)
Age (mean ± SD)	59.9 ± 16.6 (range 20-83 y)
>64 y	104 (54.7%)
>74 y	35 (18.4%)
Time on dialysis (mean ± SD)	68.5 ± 100.3 mo
Men	104 (54.7%)
Hypertensives	64 (33.6%)
Diabetics	18 (9.4%)
Dyslipemics	99 (52.1%)

Of the

Discussion

AF is a highly prevalent arrhythmia in patients with chronic renal insufficiency in our hemodialysis program. The prevalence was 13.6% of the patients and was directly related to age, being present in 16.4% of the patients >64 years of age and in more than a third of those >74 years of age. These levels imply a percentage >3 times that observed in general population groups in whom the arrhythmia has been quantified as 4.7%³⁴ or 5.9%³⁵ of those individuals ≥65 years of age. Only 1 of the 86

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Chronic kidney disease (CKD) is an independent risk factor for presenting atrial fibrillation (AF), which conditions an increased risk already present in CKD of suffering a thromboembolic event. And this risk is even higher in the hemodialysis (HD) population. On the other hand, in CKD patients and even more so in HD patients, the probability of suffering serious bleeding is also higher. Therefore, there is no consensus on whether or not to anticoagulate this population.
Taking as a model what is advised for the general population, the most common attitude among nephrologists has been to opt for anticoagulation, even though there is no randomized studies to support it.
Classically, anticoagulation has been done with vitamin K antagonists, at high cost for our patients: severe bleeding events, vascular calcification, and progression of nephropathy, among other complications.
With the emergence of direct-acting anticoagulants, a hopeful outlook was opened in the field of anticoagulation, as they were postulated as more effective and safer drugs than antivitamin K. However, in clinical practice, this has not been the case.
In this paper we review various aspects of AF and its anticoagulant treatment in the HD population.
La enfermedad renal crónica (ERC) es un factor de riesgo independiente para presentar fibrilación auricular (FA) lo que condiciona un incremento del riesgo ya presente en la ERC de sufrir un evento tromboembólico; y este riesgo es mayor aún en la población en hemodiálisis (HD). Por otro lado, en estos pacientes también es mayor la probabilidad de sufrir una hemorragia grave. Por ello, decidir si se debe anticoagular o no a un paciente con FA en diálisis es motivo de controversia entre la comunidad nefrológica.
Tomando como modelo lo aconsejado para la población general, la actitud más común entre los nefrólogos ha sido la de optar por la anticoagulación, pese a que no haya estudios randomizados que lo apoyen.
Clásicamente la anticoagulación se ha hecho con antagonistas de la vitamina K, con alto coste para nuestros pacientes: eventos hemorrágicos graves, calcificación vascular y progresión de la nefropatía entre otras complicaciones.
Con el surgimiento de los anticoagulantes de acción directa, se abrió un panorama esperanzador en el campo de la anticoagulación, al postularse como fármacos más eficaces y seguros que los antivitamina K. Sin embargo, en la práctica clínica, esto no ha sido así.
En esta revisión repasamos diversos aspectos de la FA y de su tratamiento anticoagulante en la población en HD.
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The aim of this study was to identify using implantable loop recorder (ILR) monitoring the mechanisms leading to sudden death (SD) in patients undergoing hemodialysis (HD).
SD accounts for 11% to 25% of death in HD patients.
Continuous rhythm monitoring was performed using the remote monitoring capability of the ILR device in patients undergoing HD at 8 centers. Clinical, biological, and technical HD parameters were recorded and analyzed.
Seventy-one patients (mean age 65 ± 9 years, 73% men) were included. Left ventricular ejection fraction was <50% in 16%. Twelve patients (17%) had histories of atrial fibrillation or flutter at inclusion. During a mean follow-up period of 21.3 ± 6.9 months, 16 patients died (14% patient-years), 7 (44%) of cardiovascular causes. Four SDs occurred, with progressive bradycardia followed by asystole. The incidence of patients presenting with significant conduction disorder and with ventricular arrhythmia was 14% and 9% patient-years, respectively. In multivariate survival frailty analyses, a higher risk for conduction disorder was associated with plasma potassium >5.0 mmol/l, bicarbonate <22 mmol/l, hemoglobin >11.5 g/dl, pre-HD systolic blood pressure >140 mm Hg, the longer interdialytic period, history of coronary artery disease, previous other arrhythmias, and diabetes mellitus. A higher risk for ventricular arrhythmia was associated with potassium <4.0 mmol/l, no antiarrhythmic drugs, and previous other arrhythmias. With ILR monitoring, de novo atrial fibrillation or flutter was diagnosed in 14 patients (20%).
ILR may be considered in HD patients prone to significant conduction disorders, ventricular arrhythmia, or atrial fibrillation or flutter to allow early identification and initiation of adequate treatment. Therapeutic strategies reducing serum potassium variability could decrease the rate of SD in these patients. (Implantable Loop Recorder in Hemodialysis Patients [RYTHMODIAL]; NCT01252823)
Cardiovascular Disease in Chronic Kidney Disease
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Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in patients with chronic kidney disease (CKD). The increased risk of CVD begins during the earlier stages of CKD before the onset of kidney failure. Although patients with CKD have a very high prevalence of traditional CVD risk factors such as diabetes and hypertension, they are also exposed to other nontraditional, uremia-related CVD risk factors such as abnormal calcium-phosphorus metabolism and inflammation. Although some of the burden of CVD in CKD may be due to atherosclerosis, it is apparent that patients with CKD also have a high prevalence of vascular stiffness due to nonatherogenic causes and disorders of left ventricular structure and function. In this chapter, we discuss the epidemiology and pathophysiology of CVD in patients with CKD, with a focus on dialysis patients and nontransplant recipients with stages 3 to 4 CKD. We also discuss the different manifestations of CVD in kidney disease and review diagnostic and therapeutic options.
Oral Anticoagulants to Prevent Stroke in Nonvalvular Atrial Fibrillation in Patients With CKD Stage 5D: An NKF-KDOQI Controversies Report
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Stroke risk may be more than 3-fold higher among patients with chronic kidney disease stage 5D (CKD-5D) compared to the general population, with the highest stroke rates noted among those 85 years and older. Atrial fibrillation (AF), a strong risk factor for stroke, is the most common arrhythmia and affects >7% of the population with CKD-5D. Warfarin use is widely acknowledged as an important intervention for stroke prevention with nonvalvular AF in the general population. However, use of oral anticoagulants for stroke prevention in patients with CKD-5D and nonvalvular AF continues to be debated by the nephrology community. In this National Kidney Foundation–Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) controversies report, we discuss the existing observational studies that examine warfarin use and associated stroke and bleeding risks in adults with CKD-5D and AF. Non–vitamin K–dependent oral anticoagulants and their potential use for stroke prevention in patients with CKD-5D and nonvalvular AF are also discussed. Data from randomized clinical trials are urgently needed to determine the benefits and risks of oral anticoagulant use for stroke prevention in the setting of AF among patients with CKD-5D.
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La mortalité cardiovasculaire des patients hémodialysés reste un problème majeur. La prévalence et l’incidence de la fibrillation auriculaire dans cette population sont également plus importantes que dans la population générale. L’indication d’un traitement par antivitamine K (AVK) dans ce contexte de fibrillation auriculaire est à mettre en balance avec le risque hémorragique, déjà majoré dans cette population. Malheureusement, et contrairement à la population générale, l’indication de l’anticoagulation basée sur des scores de risque embolique ou hémorragique n’est pas aussi clairement établie dans la population de patients hémodialysés. Aucune étude prospective randomisée n’a analysé la balance bénéfice/risque d’un traitement anticoagulant chez le sujet hémodialysé. Cet article fait l’état des lieux actuel de la littérature, témoignant de la prévalence des événements thromboemboliques, mais également hémorragiques, dans la population de patients hémodialysés. L’impact du traitement par AVK dans cette population spécifique est également revu. À ce stade de nos connaissances, la prise en charge des patients reste à individualiser en fonction de leurs caractéristiques.
Cardiovascular mortality of hemodialysis patients remains a major problem. The prevalence and incidence of atrial fibrillation in this population are more important than in the general population. The indication of antivitamin K therapy (AVK) in this context of atrial fibrillation must be weighted against the increased risk of bleeding. Unfortunately, and contrary to the general population, an indication of anticoagulation based on embolic or hemorrhagic risk scores is not as clearly established in the hemodialysis population. No prospective randomized study has investigated the benefit/risk balance of anticoagulant treatment in hemodialysis subjects. This article is a review of the current literature on this topic, showing the prevalence of thromboembolic but also bleeding events in the hemodialysis population. The impact of AVK treatment in this specific population is also reviewed. To the best of our knowledge, the indication of treatment must be individualized.

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^☆: Reprint requests: Eduardo Vázquez, C/ Navas de Tolosa 4 y 6; Portal 1; 6°D, 23001 Jaén, Spain. E-mail: [email protected]

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ElectrophysiologyInfluence of atrial fibrillation on the morbido-mortality of patients on hemodialysis☆

Abstract

Section snippets

Methods

Results

Discussion

Am J Med

Lancet

J Am Coll Cardiol

Am J Cardiol

Am J Kidney Dis

Am J Kidney Dis

Kidney Int

Am J Kidney Dis

Kidney Int

Am J Kidney Dis

Lancet

Am J Cardiol

Am J Kidney Dis

Am Heart J

Accelerated atherosclerosis in prolonged maintenance hemodialysis

N Engl J Med

Clinical epidemiology of cardiovascular disease in chronic renal disease

Am J Kidney Dis

Report on management of renal failure in Europe, XXII, 1991

Nephrol Dial Transplant

Impact of atrial fibrillation on the risk of death

Circulation

Decrease in mortality in patients with a hospital diagnosis of atrial fibrillation in Denmark during the period 1980-1993

Eur Heart J

Idiopathic atrial fibrillation as a risk for mortality

Eur Heart J

Atrial fibrillation as an independent risk factor for stroke: the Framingham study

Stroke

Risk factors for stroke in type 2 diabetes mellitus: United Kingdom prospective study (UKPDS)

Arch Intern Med

Lone atrial fibrillation in elderly persons: a marker for cardiovascular risk

Arch Intern Med

Electrophysiology
Influence of atrial fibrillation on the morbido-mortality of patients on hemodialysis☆