Atrial Fibrillation in Advanced Chronic Kidney Disease: A Survey of Current Management in Australia and New Zealand.

Abstract

Aim: There is limited evidence to support the use of oral anticoagulation (OAC) in people with advanced chronic kidney disease (CKD) and atrial fibrillation (AF). The aim of this study is to characterise the practice patterns and priorities of clinicians in the management of non-valvular AF and primary prevention of AF-related stroke in people with stage 4-5D CKD.

Methods: This was an annonymous, multiple-choice, electronic survey distributed to and undertaken by nephrology and cardiology clinicians in Australia and New Zealand.

Results: Responses eligible for analysis were received from 181 clinicians (121 nephrology and 60 cardiology respondents). Management with close specialty collaboration was reported by 47% of all respondents. OAC use was predominantly based on estimated individual stroke risk (i.e., CHA₂DS₂-VASc score) in people with stage 4 CKD and kidney transplant recipients. In stage 5/5D CKD, nephrology respondents were more likely to withhold all antithrombotic therapy or individualise OAC use (p < 0.05), whilst cardiology respondents were more likely to defer OAC decision-making to another specialist (p < 0.01). Varied use and dosing of OAC agents were noted between specialties. Left atrial appendage occlusion experience was limited amongst nephrology respondents but cardiology respondents would consider in individualised cases. Impact of CKD severity was noted in some rate and/or rhythm control management decisions.

Conclusions: This survey provides important contemporary insights into the management of AF in people with advanced CKD in Australia and New Zealand. There was inter- and intra-specialty heterogeneity in practice, highlighting the need for multidisciplinary care and research to improve cardiovascular outcomes in this population.