Arrhythmia in CKD Requires Vigilance, but Suitable Therapies Exist

Managing patients who have chronic kidney disease (CKD) and arrhythmias can be complicated, but effective therapies are available, according to a new review.

In an article in European Cardiology Review, the authors explained what the latest research says about treating these patients. They began by noting that the risk of arrhythmia increases with age and that atrial fibrillation (AF) is the most common sustained arrhythmia.

“CKD is even more prevalent than sustained arrhythmia and is associated with an excess of acquired arrhythmia of multiple types, and AF in particular,” the investigators wrote.

Yet, while monitoring patients in response to symptoms can be one way of detecting arrhythmia in these patients, the investigators said existing evidence suggests a significant number of patients with arrhythmias are asymptomatic. One study of cardiac-asymptomatic patients on dialysis found that 51% had AF, 24% had significant bradycardia, and 23% had ventricular tachycardia, the investigators noted.

Turning their attention to potential causes of arrhythmia in CKD, the authors highlighted that diabetes and hypertension both have been linked with risk of arrhythmias and end-stage renal failure.

“In both cases, CKD and AF are usually late effects of the underlying condition, but that underlying condition commonly goes undiagnosed until the consequences bring it to light,” they wrote.

There are also several less common mechanisms of arrhythmia in renal failure. Examples include Fabry disease, mineral bone disorders, autonomic dysfunction, and inflammation, the review said.

“With so many mechanisms to choose from, the difficulty lies not in determining whether an association exists between CKD and arrhythmias but in determining the most important mechanisms of connection,” the authors wrote.

An important first step is to document symptoms. Since these can be fleeting, electronic monitoring devices are available to identify and record symptoms.

In terms of therapy, the investigators said physicians should first attempt to address any modifiable underlying conditions while trying to mitigate risks associated with the arrhythmia. For instance, heart valve disease and myocardial ischemia should be corrected when possible.

“With underlying conditions corrected, management of renal problems optimized, and the risks of thromboembolic complications mitigated, many patients will experience a resolution of arrhythmia episodes or a resolution of arrhythmia-related symptoms and will not require additional therapy,” the investigators said.

If additional therapy is required, however, physicians can face a difficult challenge. This is because renal replacement therapy can affect the venous system such that device therapy for the arrhythmia is risky. The risk of infection is higher in these patients, and the data on interventions such as implantable cardioverter defibrillators (ICDs) in patients with CKD re limited, the authors wrote.

Similarly, catheter ablation is a higher-risk procedure in CKD; however, the authors noted evidence exists that the procedure can be successful and even improve renal function over the long term. Drug therapy is another potential option, although the investigators said there is reason for physicians to be cautious, given a relative lack of data on the risks of antiarrhythmic drugs in patients with CKD.

In their conclusion, the investigators said it can be difficult to know how to optimally manage patients with arrhythmia and CKD, but they said a range of potential therapies exist and new ones are emerging.

“Optimal management of arrhythmia not only improves the quality of life of many patients but can, in some cases, extend life and slow the progression of CKD,” they concluded.

Reference

Akhtar Z, Leung LW, Kontogiannis C, Chung I, Bin Waleed K, Gallagher MM. Arrhythmias in chronic kidney disease. Eur Cardiol. Published online March 7, 2022. doi:10.15420/ecr.2021.52