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While AF patients with CKD stages G1-G3b can be managed similarly to non-CKD patients, optimal stroke prevention and rhythm control in stages G4-G5 remain uncertain due to limited evidence, higher recurrence rates, and elevated bleeding risks.
The prevalence of atrial fibrillation (AF) is high among patients with chronic kidney disease (CKD). While patients with CKD Stages G1 – G3b may be treated similarly to patients without CKD, little evidence guides therapeutic strategies for CKD G4 - G5 patients. Dosing of most drugs used for rate and rhythm control requires adjustment to kidney function. Recurrence rates after cardioversion and ablation for rhythm control are higher in patients with advanced CKD than those without it. Regarding the prevention of stroke and systemic embolism, the benefit-to-risk ratio of oral anticoagulation (OAC) is disputed among patients with CKD stages G4 - G5 with AF, in particular among those receiving hemodialysis given their high risk for severe bleeding events. Novel strategies for stroke and systemic embolism prevention, particularly factor XI inhibitors and left atrial appendage occlusion (LAAO), have not yet fulfilled their initial promise as safe and effective alternatives.
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Schneppe et al. (2026) conducted a review in Atrial fibrillation in chronic kidney disease (CKD Stages G1-G5, including hemodialysis). Rate and rhythm control drugs, cardioversion, ablation, oral anticoagulation, factor XI inhibitors, and left atrial appendage occlusion was evaluated on Prevention of stroke and systemic embolism, and AF recurrence.
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