Chang David Ray, Chiang Hsiu-Yin, Hsiao Ya-Luan, Le Uyen-Minh, Hong Yu-Cuyan, Chang Shih-Sheng, Chen Ke-Wei, Lin Che-Chen, Yeh Hung-Chieh, Ting I-Wen, Chen Pei-Chun, Chen Hung-Lin, Chang Kuan-Cheng, Kuo Chin-Chi
AKI-CARE (Clinical Advancement, Research and Education) Center, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan; Division of Nephrology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan; Big Data Center, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan.
Big Data Center, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan.
Atherosclerosis. 2025 Feb;401:119055. doi: 10.1016/j.atherosclerosis.2024.119055. Epub 2024 Nov 23.
The interaction between full-spectrum chronic kidney disease (CKD) and atrial fibrillation (AF) on ischemic stroke and all-cause mortality risk, particularly in stage 4 and 5 CKD, remains undetermined.
This matched cohort study identified incident AF patients using the International Classification of Disease codes and electrocardiograms from the Clinical Research Data Repository of China Medical University Hospital between 2003 and 2020. For each AF patient, we selected four controls without AF and matched them by age, sex, eGFR within 10 mL/min/1.73 m, end-stage kidney disease (ESKD) vintage, and diagnosis year. Multivariable Cox proportional hazard models were utilized to assess the interaction between AF and CKD on three-year ischemic stroke and all-cause mortality outcomes.
Within a total of 10,155 patients and 39,439 controls, incidence rates were 3.03 % and 1.48 % for ischemic stroke and 15.6 % and 9.53 % for overall mortality, respectively. In AF, the stroke risk was the highest among patients with stage 4 and 5-ND (non-dialysis) CKD with adjusted hazard ratio (aHR) of 3.31 (95 % CI, 2.46-4.45) and 2.73 (1.88-3.96), respectively. The mortality risk difference varied between 45% and 177 % with the highest difference noted in ESKD (aHR 3.36 [95 % CI, 2.84-3.98] in AF vs. 1.59 [95 % CI, 1.28-1.96] in non-AF; interaction p < 0.001). Anticoagulation therapy significantly lowered the mortality risk among patients with AF and advanced CKD (3-way interaction p < 0.001).
The risk of ischemic stroke and overall mortality was particularly high among patients with concurrent AF and stage 4 and 5-ND CKD, underscoring the urgent evidence to optimize prognosis.
全谱慢性肾脏病（CKD）与心房颤动（AF）之间对缺血性卒中及全因死亡风险的相互作用，尤其是在4期和5期CKD患者中，仍未明确。
这项匹配队列研究利用疾病国际分类编码和心电图，从中国医科大学附属第一医院临床研究数据储存库中识别出2003年至2020年期间的新发AF患者。对于每例AF患者，我们选择4例无AF的对照，并按照年龄、性别、估算肾小球滤过率（eGFR）在10 mL/min/1.73m²以内、终末期肾病（ESKD）病程及诊断年份进行匹配。采用多变量Cox比例风险模型评估AF与CKD之间对三年缺血性卒中和全因死亡结局的相互作用。
在总共10155例患者和39439例对照中，缺血性卒中的发生率分别为3.03%和1.48%，总体死亡率分别为15.6%和9.53%。在AF患者中，4期和5期非透析（ND）CKD患者的卒中风险最高，校正风险比（aHR）分别为3.31（95%CI，2.46 - 4.45）和2.73（1.88 - 3.96）。死亡风险差异在45%至177%之间，ESKD患者差异最大（AF患者的aHR为3.36 [95%CI，2.84 - 3.98]，非AF患者为1.59 [95%CI，1.28 - 1.96]；相互作用p < 0.001）。抗凝治疗显著降低了AF合并晚期CKD患者的死亡风险（三方相互作用p < 0.001）。
AF合并4期和5期ND CKD患者的缺血性卒中和总体死亡风险特别高，这凸显了优化预后的迫切证据需求。
