Chronic kidney disease in patients with atrial fibrillation: Effects on outcomes with and without early rhythm control.

Clin Res Cardiol (2026). DOI 10.1007/s00392-026-02870-1
N. Schenker (Hamburg)¹, K. Borof (Hamburg)², C. Schmidt-Lauber (Hamburg)³, A. Goette (Paderborn)⁴, G. Breithardt (Münster)⁵, J. Camm (London)⁶, H. J. Crijns (Maastricht)⁷, L. Eckardt (Münster)⁸, A. Elvan (Zwolle)⁹, L. Fabritz (Hamburg)², I. Van Gelder (Groningen)¹⁰, M. Gulizia (Catania)¹¹, L. Haegeli (Zürich)¹², H. Heidbuchel (Antwerpen)¹³, J. Kautzner (Praha)¹⁴, M. Lemoine (Hamburg)¹, A. Ng (Leicester)¹⁵, R. Schnabel (Hamburg)¹⁶, A. Suling (Hamburg)¹⁷, L. Szumowsky (Warschau)¹⁸, S. Thermistoclakis (Venice)¹⁹, P. E. Vardas (Heraklion)²⁰, K. Wegscheider (Hamburg)¹⁷, S. Willems (Hamburg)²¹, A. Zapf (Hamburg)¹⁷, A. Metzner (Hamburg)¹, A. Rillig (Hamburg)¹, P. Kirchhof (Hamburg)^22
1Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie mit Schwerpunkt Elektrophysiologie Hamburg, Deutschland; ²Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Hamburg, Deutschland; ³III. Department of Medicine, University Medical Center Hamburg-Eppendorf Hamburg, Deutschland; ⁴St. Vincenz-Krankenhaus GmbH Medizinische Klinik II, Kardiologie Paderborn, Deutschland; ⁵Münster, Deutschland; ⁶St. Georges Hospital Cardiovascular Research Group London, Großbritannien; ⁷Maastricht UMC+Heart+Vascular Center Department of Cardiology Maastricht, Niederlande; ⁸Universitätsklinikum Münster Rhythmologie, DEPKA Kardiologie und Angiologie Münster, Deutschland; ⁹Isala Klinieken Weezenlanden Zwolle, Niederlande; ¹⁰University Medical Center Groningen Department of Cardiology Groningen, Niederlande; ¹¹13 Cardiology Division, Garibaldi-Nesima Hospital Catania, Italien; ¹²Zürich, Schweiz; ¹³University of Antwerp Department of Cardiology Antwerpen, Belgien; ¹⁴Institute for Clinical and Experimental Medicine (IKEM) Department of Cardiology Praha, Tschechische Republik; ¹⁵Leicester, Großbritannien; ¹⁶Universitäres Herz- und Gefäßzentrum Hamburg Allgemeine und Interventionelle Kardiologie Hamburg, Deutschland; ¹⁷Universitätsklinikum Hamburg-Eppendorf Zentrum für Experimentelle Medizin, Institut für Medizinische Biometrie und Epidemiologie Hamburg, Deutschland; ¹⁸Warschau, Polen; ¹⁹Venice, Italien; ²⁰Heraklion University Hospital Department of Cardiology Heraklion, Griechenland; ²¹Asklepios Klinik St. Georg Kardiologie & internistische Intensivmedizin Hamburg, Deutschland; ²²Universitätsklinikum Hamburg-Eppendorf Klinik für Kardiologie Hamburg, Deutschland

Background:

Atrial fibrillation (AF) and chronic kidney disease (CKD) increase cardiovascular risk, while early rhythm control reduces it.

Objective:

To determine the effects of CKD on cardiovascular events and on early rhythm control therapy in the EAST-AFNET 4 trial.

Methods:

This predefined secondary analysis of EAST-AFNET 4 assessed the effect of CKD defined by estimated glomerular filtration rate (eGFR) as continuous parameter and by kidney function stages. The primary outcome consisted of cardiovascular death, stroke, hospitalization for worsening heart failure or acute coronary syndrome. The safety outcome was a composite of death, stroke or serious adverse events related to rhythm control therapy.

Results:

In 2742/2789 (98.3%) patients with baseline creatinine concentrations, 23% had CKD (eGFR <60ml/min/1.73m²). Patients with CKD were older (CKD 74±7.4, no CKD 69±8.3 years, p<0.001) and had higher CHA₂DS₂-VASc scores (CKD 4±1.4, no CKD 3.2±1.2, p<0.001). Patients with better kidney function experienced less primary outcome events over 5.1 years of follow-up (hazard ratio HR 0.98 [0.97;0.99] per ml eGFR decrease). Early rhythm control reduced the primary outcome in patients without CKD (early rhythm control 3.4%/100 patient-years, usual care 4.1%/100 patient-years, HR 0.84, p<0.001) and patients with CKD (early rhythm control 5.8%/100 patient-years, usual care 8.5%/100 patient-years, HR 0.67, p<0.001, p_interaction=0.133). CKD was associated with increased safety outcomes without interaction with early rhythm control (p_interaction=0.927).

Conclusion:

Chronic kidney disease increases the risk of cardiovascular events in patients with recently diagnosed atrial fibrillation and stroke risk factors. Early rhythm control retains its effectiveness with and without chronic kidney disease.

Table 1:

	GFR ≥ 60ml/min/1.73m²		GFR < 60ml/min/1.73m²
	Early rhythm control	Usual care	Early rhythm control	Usual care
First primary outcome - events/person-yr (incidence/100 person-yr)	173/5068 (3.4)	204/4949 (4.1)	72/1238 (5.8)	110/1293 (8.5)