Atrial Fibrillation and Risk of ESRD in Adults with CKD

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.

Keywords: Atrial Fibrillation; Electrocardiography; Humans; Kidney Failure, Chronic; Prospective Studies; Risk; cardiovascular disease; chronic kidney disease; diabetes mellitus; renal progression.

Figure 1.

Multivariable association of incident atrial fibrillation with risk of ESRD among subgroups with CKD in the Chronic Renal Insufficiency Cohort Study (adjusted for demographics, clinical site, proteinuria, eGFR, tobacco use, heart failure, coronary heart disease, hypertension, diabetes, systolic BP, body mass index, hemoglobin, diuretic use, and angiotensin converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB) use). The P values are for the interactions between the incident atrial fibrillation indicator and the covariates defining these subgroups. 95% CI, 95% confidence interval; HR, hazard ratio.