Clinical impact of cardiac ejection fraction and atrial fibrillation on elderly hemodialysis patients

BACKGROUND This study aimed to investigate all-cause mortality in elderly patients starting hemodialysis (HD) according to left ventricular ejection fraction LVEF and atrial fibrillation (AF). METHODS We analyzed 1,137 incident HD patients aged ≥70 years from a retrospective multicenter cohort of the Korean Society of Geriatric Nephrology. All-cause mortality was evaluated within the first 6 months and beyond 6 months using a landmark analysis (median follow-up, 3.7 years) according to LVEF and AF status. Sequential Cox proportional hazards models were applied, adjusted for demographic and clinical factors. RESULTS Patients were classified into four groups according to LVEF (≥50% vs. <50%) and AF status. After full adjustment, neither reduced LVEF nor AF was independently associated with 6-month mortality. Early mortality was mainly associated with older age, lower serum albumin, and impaired mobility. In the 6-month landmark analysis, compared with patients with preserved LVEF and no AF, those with reduced LVEF without AF (hazard ratio HR 1.29, 95% confidence interval CI 1.01-1.65), preserved LVEF with AF (HR 1.35, 95% CI 1.02-1.80), and reduced LVEF with AF (HR 1.69, 95% CI 1.03-2.79) had progressively higher long-term mortality risks. CONCLUSIONS In elderly patients initiating HD, reduced LVEF and AF were independently associated with higher long-term mortality, whereas short-term mortality was predominantly driven by frailty and nutritional status rather than cardiac factors. These findings highlight the importance of time-specific risk stratification and integrated cardiovascular and geriatric management in this population.