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Dilemmas in the Management of Atrial Fibrillation in Chronic Kidney Disease

Holger Reinecke^*, Eva Brand, Rolf Mesters, Wolf-Rüdiger Schäbitz, Marc Fisher^||, Hermann Pavenstädt and Günter Breithardt^*

^* Department of Cardiology and Angiology (Medizinische Klinik und Poliklinik C), Department of Nephrology (Medizinische Klinik und Poliklinik D), Department of Hematology and Oncology (Medizinische Klinik und Poliklinik A), and Department of Neurology (Klinik und Poliklinik für Neurologie), University Hospital of Muenster, Muenster, Germany; and ^|| Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts

Correspondence: Dr. Holger Reinecke, Medizinische Klinik und Poliklinik C, 48129 Münster, Germany. Phone: ++49-251-834-7617; Fax: ++49-251-834-7864; E-mail: hreinecke{at}gmx.net

Patients with chronic kidney disease (CKD) have an increased risk for cardiovascular morbidity and mortality. Little attention has been paid to the problem of atrial fibrillation, although this arrhythmia is very frequent with a prevalence of 13 to 27% in patients on long-term hemodialysis. Because of the large number of pathophysiologic mechanisms involved, these patients have a high risk for both thromboembolic events and hemorrhagic complications. Stroke is a frequent complication in CKD: The US Renal Data System reports an incidence of 15.1% in hemodialysis patients compared with 9.6% in patients with other stages of CKD and 2.6% in a control cohort without CKD. The 2-yr mortality rates after stroke in these subgroups were 74, 55, and 28%, respectively. Although oral coumadin is the treatment of choice for atrial fibrillation, its use in patients with CKD is reported only in limited studies, all in hemodialysis patients, and is associated with a markedly increased rate of bleeding compared with patients without CKD. With regard to the high risk for stroke and the conflicting data about oral anticoagulation, an individualized stratification algorithm is presented based on relevant studies.

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Copyright © 2009 by the American Society of Nephrology. Online ISSN: 1533-3450 Print ISSN: 1046-6673