F- 06 : Cardiovascular complications
E- 02 : Auricular fibrillation
Incidence and risk factors for new-onset atrial fibrillation among patients
with end-stage renal disease undergoing renal replacement therapy
Jo-Nan Liao1,2,7, Tze-Fan Chao1,2,7, Chia-Jen Liu3,4, Kang-Ling Wang1,2, Su-Jung Chen4,5, YennJiang Lin1,2, Shih-Lin Chang1,2, Li-Wei Lo1,2, Yu-Feng Hu1,2, Ta-Chuan Tuan1,2, Fa-Po Chung1,2,
Tzeng-Ji Chen6 and Shih-Ann Chen1,2
1Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
2Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University,
Taipei, Taiwan
3Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital,
Taipei, Taiwan
4Institute of Public Health and School of Medicine, National Yang-Ming University, Taipei, Taiwan
5Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, Taipei,
Taiwan
6Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
Correspondence: Shih-Ann Chen, Division of Cardiology, Department of Medicine, Taipei Veterans
General Hospital, No. 201, Section 2, Shih-Pai Road, Taipei, Taiwan. E-mail:
epsachen@ms41.hinet.net
Journal : Kidney International
Year : 2015 / Month : June
Volume : 87
Pages : 1209–1215
doi:10.1038/ki.2014.393
ABSTRACT
Atrial fibrillation (AF) is prevalent in end-stage renal disease (ESRD) patients and negatively impacts
patient outcomes.
We explored the incidence and risk factors for new-onset AF among patients with ESRD undergoing
renal replacement therapy, without a prior history of AF, retrieved from Taiwan’s National Health
Insurance Research Database (NHIRD). For each of 134,901 patients with ESRD, one age- and
gender-matched control and one similarly matched patient with chronic kidney disease (CKD), a total of
404,703 patients, were selected from the NHIRD. The study endpoint was the occurrence of new-onset
AF and patients were followed an average of 5.1 years. The incidence rates of AF were 12.1, 7.3, and
5.0 per 1000 person-years for ESRD, CKD, and control patients, respectively. Among patients with
ESRD, age, hypertension, heart failure, coronary artery disease, peripheral arterial occlusive disease,
and chronic obstructive pulmonary disease were significant risk factors for new-onset AF. Thus,
patients with ESRD had a significantly higher risk of new-onset AF. The presence of multiple risk
factors was associated with a higher possibility of AF occurrence.
Keywords: atrial fibrillation; chronic kidney disease; end-stage renal disease; risk factors
COMMENTS
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in clinical practice, and carries a
fivefold risk of stroke, a threefold incidence of heart failure (HF), and an increased mortality.
AF is usually divided into valvular or non-valvular types. The most widely used classification divides AF
into paroxysmal and non-paroxysmal, including persistent or permanent types, based on the duration
and chronicity of each episode. With regard to AF-related thromboembolic events, the type of AF has
not been taken into account in present practical guidelines, because previous studies have
demonstrated that the risk of thromboembolism was similar for paroxysmal and non-paroxysmal AF.
Renal dysfunction has been documented to be significantly associated with new-onset AF and AFrelated stroke.
In this cohort, the mean patient age was 61.7±14.3 years, and 49.5% were male in all three groups.
Compared with controls, ESRD and CKD patients had a higher percentage of hypertension (HTN),
diabetes mellitus, HF, coronary artery disease (CAD), peripheral arterial occlusive disease (PAOD),
cerebral vascular accident, chronic obstructive pulmonary disease (COPD), cancer, and liver cirrhosis.
In addition, these comorbidities were more prevalent in patients with ESRD than in CKD patients.
During the mean follow-up of 5.1±4.1 years, 15,745 patients had new-onset AF (6,375 in the ESRD
group, 5,056 in the CKD group, and 4,314 in controls).
Compared with controls, the hazard ratios for AF occurrence were 2.26 (95% confidence interval=2.16–
2.37, P<0.001) for ESRD and 1.28 (95% confidence interval=1.22–1.34, P<0.001) for CKD after
adjusting for age, gender, HTN, diabetes mellitus, HF, CAD, PAOD, cerebral vascular accident, COPD,
cancer, and liver cirrhosis.
Among patients with ESRD, age, HTN, HF, CAD, PAOD, and COPD were identified to be independent
risk factors for the new-onset AF. AF incidence was proportional to the number of risk factors a patient
displayed. The risk of new-onset AF increased from an hazard ratio of 1.47 (95% confidence
interval=1.32–1.63, P<0.001) to 10.35.
(95% confidence interval=6.53–16.41, P<0.001), when the number of risk factors increased from 1 to 6
in comparison with patients without risk factors.
In conclusion, the incidence rate of new-onset AF was ~12.1/1000 person-years among patients with
ESRD in a nationwide cohort study in Taiwan. Advanced age, HTN, HF, CAD, PAOD, and COPD were
significant risk factors for the occurrence of new-onset AF in ESRD patients.
Pr. Jacques CHANARD
Professor of Nephrology