Stroke, Bleeding and Death in Patients with Chronic Kidney Disease and Atrial Fibrillation

Yoav Arnson Cardiology Department, Meir Medical Center, Kfar Sava, Israel Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel Clalit Research Institute, Clalit Health Services, Tel Aviv, Israel Moshe Hoshen Clalit Research Institute, Clalit Health Services, Tel Aviv, Israel Adi Berliner-Sendrey Clalit Research Institute, Clalit Health Services, Tel Aviv, Israel Orna Reges Clalit Research Institute, Clalit Health Services, Tel Aviv, Israel Hagai Weinberg Internal medicine "B", Meir Medical Center, Kfar Sava, Israel Clalit Research Institute, Clalit Health Services, Tel Aviv, Israel Ran Balicer Clalit Research Institute, Clalit Health Services, Tel Aviv, Israel Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel Morton Leibowitz Clalit Research Institute, Clalit Health Services, Tel Aviv, Israel Meytal Avgil Tsadok Clalit Research Institute, Clalit Health Services, Tel Aviv, Israel Moti Haim Cardiology Department, Soroka Medical Center, Beer Sheva, Israel Clalit Research Institute, Clalit Health Services, Tel Aviv, Israel Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel

Background: Atrial fibrillation (AF) is associated with increased risk of stroke. Chronic kidney disease (CKD) carries a higher thromboembolic and bleeding risk. Oral anticoagulation reduces stroke risk in AF patients. However, use of oral anticoagulants among patients with comorbid CKD and AF continues to be debated due to their increased risk of bleeding. We assess the management and outcomes of AF patients with impaired renal function within a population-based cohort.

Methods: A historical prospective cohort study, conducted using the Clalit Health Services database, between 2004 and 2015. Patients with new incident AF were stratified by their baseline CKD stage based on the estimated glomerular filtration rate (eGFR >90 (stage 1), 60-89 (2), 30-59 (3), and stages 4-5 2). We compared anticoagulation treatment strategies, ischemic stroke, death, intracranial and major gastrointestinal bleeding.

Results: We identified 85,116 patients. CKD groups 2-5 patietns were older with more comorbidities compared with stage 1. Anticoagulation treatment rates were highest among CKD group 2 (49%) and lowest among patients CKD group 4-5 (27.6%). Renal dysfunction grade was associated with increased rates of death, stroke and bleeding. Stroke rates increased from 1.04 per 100-person years (PY) in CKD stage 1 to 3.72 per 100PY in CKD stages 4-5, mortality increased from 3.42 to 32.95 per 100PY and bleeding rates increased from 0.89 to 4.91 events per 100PY. Among CKD patietns, oral anti-coagulation was associated with reduced stroke and intracerebral bleeding risk. Anticoagulation use was associated with reduced risk of mortality in patients with CKD stages 1-3, but not CKD stage 4-5.

Conclusion: In this large contemporary study of AF patients, renal dysfunction was associated with progressively higher stroke, death and bleeding rates. Anticoagulation was associated with reduced stroke and intracerebral bleeding risk for patients with advanced CKD and with improved survival in CKD stages 1-3.

Presentation

Yoav Arnson