Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington
Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington.
J Am Soc Nephrol. 2022 Feb;33(2):442-453. doi: 10.1681/ASN.2021060744. Epub 2021 Dec 17.
Atrial fibrillation (AF) is highly prevalent in 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 with incident AF to study the association of CKD with management of AF.
We identified patients with newly diagnosed AF between 2010 and 2017 from two large, integrated health care delivery systems. eGFR (≥60, 45-59, 30-44, 15-29, <15 ml/min per 1.73 m) 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.
Among 115,564 patients with incident AF, 34% had baseline CKD. In multivariable models, compared with those with eGFR >60 ml/min per 1.73 m, patients with eGFR 30-44 (adjusted hazard ratio [aHR] 0.91; 95% CI, 0.99 to 0.93), 15-29 (aHR, 0.78; 95% CI, 0.75 to 0.82), and <15 ml/min per 1.73 m (aHR, 0.64; 95% CI, 0.58-0.70) had lower use of any AF therapy. Patients with eGFR 15-29 ml/min per 1.73 m had lower adjusted use of rate control agents (aHR, 0.61; 95% CI, 0.56 to 0.67), warfarin (aHR, 0.89; 95% CI, 0.84 to 0.94), and DOACs (aHR, 0.23; 95% CI, 0.19 to 0.27) compared with patients with eGFR >60 ml/min per 1.73 m. These associations were even stronger for eGFR <15 ml/min per 1.73 m. There was also a graded association between CKD severity and receipt of AF-related procedures (vs eGFR >60 ml/min per 1.73 m): eGFR 30-44 ml/min per 1.73 (aHR, 0.78; 95% CI, 0.70 to 0.87), eGFR 15-29 ml/min per 1.73 m (aHR, 0.73; 95% CI, 0.61 to 0.88), and eGFR <15 ml/min per 1.73 m (aHR, 0.48; 95% CI, 0.31 to 0.74).
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.
心房颤动（AF）在 CKD 中发病率很高，与心血管和肾脏预后较差相关。有关 CKD 患者 AF 药物治疗和 AF 相关治疗的使用数据有限。我们检查了一个大型“真实世界”的 AF 新发病例人群，以研究 CKD 与 AF 管理之间的关联。
我们从两个大型综合医疗服务系统中确定了 2010 年至 2017 年期间新诊断为 AF 的患者。通过至少两次间隔至少 90 天的门诊血肌酐测量计算 eGFR（≥60、45-59、30-44、15-29、<15 ml/min per 1.73 m）。从电子病历中确定 AF 药物和治疗方法。我们使用多变量 Fine-Gray 亚分布风险回归来检验 CKD 严重程度与靶向 AF 治疗的相关性。
在 115564 名患有 AF 的患者中，34%的患者存在基线 CKD。在多变量模型中，与 eGFR >60 ml/min per 1.73 m 的患者相比，eGFR 30-44 ml/min per 1.73 m（调整后的危险比 [aHR]，0.91；95%CI，0.99 至 0.93）、15-29 ml/min per 1.73 m（aHR，0.78；95%CI，0.75 至 0.82）和<15 ml/min per 1.73 m（aHR，0.64；95%CI，0.58 至 0.70）的 AF 治疗使用率较低。eGFR 15-29 ml/min per 1.73 m 的患者，使用心率控制药物（aHR，0.61；95%CI，0.56 至 0.67）、华法林（aHR，0.89；95%CI，0.84 至 0.94）和 DOACs（aHR，0.23；95%CI，0.19 至 0.27）的调整使用率较低，与 eGFR >60 ml/min per 1.73 m 的患者相比。eGFR <15 ml/min per 1.73 m 的患者中，这种关联更为明显。CKD 严重程度与 AF 相关治疗的接受程度之间也存在分级关联（与 eGFR >60 ml/min per 1.73 m 相比）：eGFR 30-44 ml/min per 1.73（aHR，0.78；95%CI，0.70 至 0.87）、eGFR 15-29 ml/min per 1.73 m（aHR，0.73；95%CI，0.61 至 0.88）和 eGFR <15 ml/min per 1.73 m（aHR，0.48；95%CI，0.31 至 0.74）。
在新诊断为 AF 的成年人中，CKD 严重程度与心率控制药物、抗凝药物和 AF 治疗的使用率降低相关。需要更多关于 CKD 人群中 AF 治疗的疗效和安全性的数据，以便为治疗策略提供信息。
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