Review Article Atrial fibrillation in CKD Luminita Voroneanu a, ⁎, Alberto Ortiz b , Ionut Nistor a , Adrian Covic a a Nephrology Department, Dialysis and Renal Transplant Center, “C.I. Parhon” University Hospital, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania b Nephrology and Hypertension Department, IIS-Fundacion Jimenez Diaz and School of Medicine, Madrid, Spain abstract article info Article history: Received 22 February 2016 Received in revised form 7 April 2016 Accepted 9 April 2016 Available online xxxx Atrial fibrillation (AF), one of the most common dysrhythmia in clinical practice, remains frequently in people with chronic kidney disease (CKD). AF is associated with a fivefold risk of stroke, a threefold incidence of heart failure, and an increased risk of death. Co-existence of AF and CKD raises substantially morbidity and mortality. Moreover, the optimal treatment approach (rate versus rhythm control) remains debated due to lack of hard ev- idence. Oral anticoagulation is challenging, since these patients have both a prothrombotic state and an increased risk of stroke and an inherent platelet and vascular dysfunction and an amplified rate of bleeding. Although promising, the newer anticoagulation agents were not tested in severe CKD. Furthermore, fatal bleeding has been reported. © 2016 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. Keywords: Arrhythmia Cardiovascular outcomes Chronic kidney failure Hemodialysis 1. Introduction Chronic kidney disease (CKD) is associated with an increased cardio- vascular (CV) morbidity and mortality [1]. Among CKD patients in the United States, CV mortality is approximately 30 times higher than in matched individuals from the general population and the risk for ar- rhythmogenic death is one of the highest from any other population [2,3]. Atrial fibrillation (AF) is the most common dysrhythmia in clinical practice and it is independently associated with CV mortality [4]. Nu- merous studies showed that hemodialysis (HD) patients have a high prevalence of ventricular arrhythmias and an increased incidence of sudden cardiac death [4,5], but for a long time, AF did not cause the same amount of research attention as other area of cardiac pathology [2,6]. In the general population, AF transfers a fivefold risk of stroke, a threefold incidence of heart failure, and an increased risk of death [7]. According to recent European and American guidelines, AF could be classified in two types: valvular or non-valvular [8,9]. Several classifica- tion systems were proposed for non-valvular AF, but none accounted for all types of AF [8]. 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 [10]. 2. Epidemiology of AF in non-dialysis CKD, dialysis, and transplantation In the general population, the prevalence of AF is estimated to range between 0.4 and 1% depending on age; its prevalence doubles with each decade of age, reaching approximately 8% in patients over 80 years old [11]. CKD, defined as either pathological albuminuria (N 30 mg/24 h) or decreased GFR (b 60 ml/min/1.73 m 2 ), is associated with a higher inci- dence and prevalence of AF, compared to the general population [12,13]. Data on the epidemiology of AF in patients with CKD are limited. The incidence of AF was increased in hypertensive patients with CKD (ad- justed HR 2.18, 95% CI 1.2–3.9), but the relationship was statistically sig- nificant only among patients with advanced CKD (stages 4 and 5) [14]. Additionally, a significant and progressively higher risk of incident AF starting with mildly decreased kidney function to more advanced renal failure was reported in the Atherosclerosis Risk In Communities cohort (HR 3.2; 95% CI 2.0–5.0 in CKD stage 4 and 1.6 95% CI 1.27–2.13 in CKD stage 3) [12]. Similarly, data from a Medicare cohort estimated the 2-year incidence of AF at 12.2% for patients with CKD stages 1 and 2 (that is, patients with pathological albuminuria and GFR ≥ 60 ml/min/1.73 m 2 ), at 14.4% for stages 3–5, and 13.4% for un- known stage, compared with 7.5% for patients without CKD [15]. In a re- cent large cohort of African-American and white US adults, CKD was associated with an increased prevalence of AF; the prevalence of AF was highest among those with stage 4 or 5 CKD, but the association persisted across all of the CKD stages [16]. In end-stage renal disease (ESRD), the prevalence of AF varies con- siderably among studies, between 13 and 27% [17–19]. The USRDS reg- istry reported a prevalence of 13% in patients on HD and 7% in patients undergoing peritoneal dialysis [2,5,20]. Importantly, in the last 15 years, the prevalence of AF increased more than 3-fold, from 3.5% to 10.7% in HD most probably associated with higher life expectancy [6]. Recent data retrieved from Taiwan's National Health Insurance Research Data- base showed an incidence rate for AF of ~ 12.1/1000 person-years in pa- tients with ESRD, which was 1.66-fold higher than in CKD patients and 2.42-fold higher than in control patients [10]. European Journal of Internal Medicine xxx (2016) xxx–xxx ⁎ Corresponding author at: No. 50 Carol I Blvd., Iasi, Romania. Tel.: +40 740 605 556; fax: +40 232 211752. E-mail address: lumivoro@yahoo.com (L. Voroneanu). EJINME-03192; No of Pages 11 http://dx.doi.org/10.1016/j.ejim.2016.04.007 0953-6205/© 2016 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. Contents lists available at ScienceDirect European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim Please cite this article as: Voroneanu L, et al, Atrial fibrillation in CKD, Eur J Intern Med (2016), http://dx.doi.org/10.1016/j.ejim.2016.04.007