Atrial fibrillation and chronic kidney disease conundrum: an update

Atrial fibrillation (AF) is the most common cardiac arrhythmia and it is frequently encountered in chronic kidney disease (CKD) subjects. CKD patients are already at high risk for cardiovascular (CV) complications and the addition of AF further aggravates the prognosis. Data is missing regarding on how to best approach CKD patients with AF, due to lack of randomized controlled trials (RCTs). AF and CKD have a double edged-sword relationship. On one hand, there are kidney-specific mechanisms which can alter cardiac structure and predispose to AF, and on the other hand the development of AF itself can accelerate the progression of CKD. Furthermore, the synergistic effect of these two entities raises serious issues concerning the balance between bleeding and thrombotic risk. Anticoagulant treatment can be challenging, especially in end stage renal disease (ESRD), where the net clinical benefit is still unclear. The decision of rate vs. rhythm control lies mostly on general consensus, rather than on RCTs. The purpose of this review is to reinforce the symbiotic relationship between AF and CKD, to briefly summarize the current state of the therapeutic approach in this particular population and to highlight novel potential therapeutic strategies.