The effectiveness and safety of rhythm control for atrial fibrillation in patients with end-stage or chronic kidney disease

Background Although early rhythm control improves cardiovascular outcomes in patients with atrial fibrillation (AF), its use in patients with end-stage renal disease (ESRD) remains challenging. This study aimed to investigate the effectiveness and safety of rhythm control in patients with renal failure, including ESRD. Methods This population-based cohort study included 31,687 patients with AF who underwent rhythm or rate control between 2005 and 2015. Patients were categorized into three groups based on the estimated glomerular filtration rate: ESRD (<15ml/min/1.73m² or undergoing dialysis), 15– 60ml/min/1.73m², and ≥60ml/min/1.73m². The primary outcome consisted of cardiovascular death, ischemic stroke, heart failure-related hospitalization, and acute myocardial infarction. Results Among study population, 20,629 (65.1%) were male patients, with a median age of 63 years and a median follow-up period of 3.6 years. In the ESRD group, the comparative effectiveness of rhythm control was not significant (hazard ratio [HR] 0.97, 95% confidence interval [CI] 0.81 to 1.17). However, in the 15–60ml/min/1.73m² group, rhythm control was associated with a lower risk of the primary outcome than rate control (HR 0.85, 95% CI 0.74 to 0.98). This beneficial trend was consistently observed in the ≥60ml/min/1.73m² group (HR 0.87, 95% CI 0.80 to 0.93). No significant interaction was observed between renal function and treatment (p for interaction = 0.172). Rhythm control tended to have a significantly higher risk for the composite safety outcome than rate control in the ESRD group, with a significant renal function-by-treatment interaction (HR 1.29, 95% CI 1.11 to 1.50; p for interaction = 0.016). Conclusion In patients with renal failure, rhythm control was associated with better cardiovascular outcomes than rate control. However, the comparative effectiveness of rhythm control was less prominent in patients with ESRD, and the risk of adverse outcomes was higher than that of rate control. Therefore, rhythm control should be considered selectively in patients with renal failure. Clinical Perspective What is new? What are the clinical implications? ### Competing Interest Statement Dr. Joung has served as a speaker for Bayer, BMS/Pfizer, Medtronic, and Daiichi-Sankyo and has received research funds from Medtronic and Abbott. No fees were received by him, either directly or personally. The remaining authors declare no conflicts of interest. ### Funding Statement This research was supported by a grant from the Patient-Centered Clinical Research Coordinating Center (PACEN) funded by the Ministry of Health & Welfare, Republic of Korea (HC19C0130). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This study was approved by the Institutional Review Board of the Yonsei University Health System (4-2022-1241). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data for this retrospective analysis were obtained from the National Health Insurance Service (NHIS) database in Korea. The NHIS is managed by the Korean government and covers the majority (97.1%) of the Korean population, with the remaining 3% receiving medical aid. The database includes information on sociodemographic factors, inpatient and outpatient services, prescriptions, and mortality and is accessible to the public on the NHIS website ().