Background: Atrial fibrillation (AF) is highly prevalent in chronic kidney disease (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 of incident AF to study the association of CKD with management of AF.
Methods: We identified patients with newly diagnosed AF between 2010-2017 from two large, integrated healthcare delivery systems. Estimated glomerular filtration rate (eGFR) (≥60, 45-59, 30-44, 15-29, <15 ml/min/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 incident AF patients, 34% had baseline CKD. In multivariable models, compared to those with eGFR>60 ml/min/1.73 m2, patients with eGFR 30-44 (adjusted hazard ratio [aHR] 0.91, 95%CI:0.99-0.93), 15-29 (aHR 0.78, 95%CI:0.75-0.82) and <15 ml/min/1.73 m2 (HR 0.64, 95%CI:0.58-0.70) had lower use of any AF therapy. Patients with eGFR 15-29 ml/min/1.73 m2 had lower adjusted use of rate control agents (aHR 0.61, 95%CI:0.56-0.67), warfarin (aHR 0.89, 95%CI:0.84-0.94) and DOACs (aHR 0.23, 95% CI:0.19-0.27) compared to patients with eGFR>60 ml/min/1.73 m2. These associations were even stronger for eGFR <15 ml/min/1.73 m2. There was also a graded association between CKD severity and receipt of AF-related procedures (vs. eGFR>60 ml/min/1.73 m2): eGFR 30-44 ml/min/1.73 (aHR 0.78, 95%CI:0.70-0.87), eGFR 15-29 ml/min/1.73 m2 (aHR 0.73, 95%CI:0.61-0.88) and eGFR<15 ml/min/1.73 m2 (aHR 0.48, 95%CI:0.31-0.74).
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.