Atrial Fibrillation and Stroke Prevention and Management in CKD

Atrial fibrillation (AF) is the most common sustained arrhythmia, with a prevalence and incidence significantly higher in adults with CKD compared with the general population. This risk increases with reduced kidney function, affecting up to 25% of all patients with CKD and 30% of those on receiving chronic dialysis. AF is associated with increased morbidity and mortality, including higher risks of stroke, heart failure, myocardial dysfunction, and progression to kidney failure. The bidirectional relationship between AF and CKD is driven by a convergence of traditional risk factors-such as hypertension and diabetes-and CKD-specific abnormalities. Key pathophysiologic mechanisms include systemic inflammation, oxidative stress, autonomic dysfunction, and disordered mineral metabolism. These factors promote structural remodeling, atrial fibrosis, and electrical instability, creating a highly arrhythmogenic substrate. Treatment options for AF include anticoagulation, rate and rhythm control medications, other cardiovascular therapies ( e.g ., sodium glucose cotransporter 2 inhibitors), and procedures aimed at normalizing rhythm and reducing stroke risk. Patients with CKD are often undertreated with AF medications and procedures, in part because of lack of robust randomized clinical trial data on efficacy and safety, particularly with advanced CKD. This narrative review summarizes key literature on the epidemiology, risk factors, mechanisms and treatment of AF in adults with CKD, and highlights critical areas for future research.