Interaction between chronic kidney disease and atrial fibrillation on incident stroke and all-cause mortality: Matched cohort study of 49,594 patients

David Ray Chang; Hsiu-Yin Chiang; Ya-Luan Hsiao; Uyen-Minh Le; Yu-Cuyan Hong; Shih-Sheng Chang; Ke-Wei Chen; Che-Chen Lin; Hung-Chieh Yeh; I-Wen Ting; Pei-Chun Chen; Hung-Lin Chen; Kuan-Cheng Chang; Chin-Chi Kuo

doi:10.1016/j.atherosclerosis.2024.119055

Interaction between chronic kidney disease and atrial fibrillation on incident stroke and all-cause mortality: Matched cohort study of 49,594 patients

Atherosclerosis. 2024 Nov 23:401:119055. doi: 10.1016/j.atherosclerosis.2024.119055. Online ahead of print.

Authors

Affiliations

¹ 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.
² Big Data Center, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan.
³ Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
⁴ 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.
⁵ Division of Cardiology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan.
⁶ Department of Public Health, China Medical University, Taichung, Taiwan.
⁷ 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. Electronic address: chinchik@gmail.com.

PMID: 39647253
DOI: 10.1016/j.atherosclerosis.2024.119055

Abstract

Background and aims: 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.

Methods: 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 m², 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.

Results: 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).

Conclusions: 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.

Keywords: All-cause mortality; Atrial fibrillation; Chronic kidney disease; Ischemic stroke.