Acute kidney injury related to pulsed-field ablation of atrial fibrillation. Protective role of the protocol-based hydration regimen.

Abstract BACKGROUND Acute kidney injury (AKI) due to hemolysis is a potential complication of pulsed-field ablation (PFA) of atrial fibrillation (AF). OBJECTIVE This study aimed to assess the incidence and risk factors of AKI and the protective effect of a protocol-based hydration regimen in an unselected patient cohort undergoing PFA with a pentaspline catheter. METHODS Data from 501 consecutive patients treated with PFA were prospectively analysed. The first 232 (46.3%) procedures were performed without hydration, whereas the subsequent 269 (53.7%) included a predefined hydration protocol (≥2000 mL fluid). RESULTS AKI occurred in 6.4% (32 of 501) of patients (3.8% AKI 1, 1.2% AKI 2, 1.4% AKI 3). Patients with AKI had a significantly higher mean number of PF applications (105.1 ± 26.2 vs. 73.4 ± 22.2, p<0.001). Multivariable analysis identified chronic kidney disease (CKD) (OR 3.29, 95% CI 1.45–7.46, p=0.005), extensive left atrial ablation (OR 6.67, 95% CI 1.47–63.79, p=0.01​), and a higher number of PF applications (OR 1.37 per 10 applications, 95% CI 1.17–1.61, p<0.001) as AKI risk factors, while hydration was protective (OR 0.33; 95% CI 0.14–0.75, p=0.008). Predictive modelling for AKI risk defined a 5% risk at 118 pulses in non-CKD and at 78 pulses in CKD patients. CONCLUSIONS AKI after PFA occurs in approximately 6.4% of patients, predominantly mild cases. The risk increases with CKD, extensive ablation, and high PF pulse counts. Protocol-driven periprocedural hydration substantially reduces the risk of AKI.