To the Editor:
Introduction
Atrial fibrillation (AF) is the most common arrhythmia in individuals with chronic kidney (CKD), with reported prevalence of 15%-20%.1,2 It is associated with a 2- to 5-fold higher risk of stroke and cardiovascular events in individuals with CKD compared with those without.3 Despite the increasing prevalence of CKD4, there has been limited contemporary data on the epidemiological trends of AF in this population. This may hinder appropriate resource management and may affect clinical outcomes. The current study examined trends in AF incidence among a diverse group of adults in Ontario, Canada between 2011 and 2022.
Methods
This population-based study was conducted in Ontario using provincial health care administrative datasets housed at the Institute for Clinical Evaluative Sciences (ICES). These datasets were linked using unique encoded identifiers. Included were Ontarians aged ≥ 18 years with a diagnosis of AF and receiving maintenance dialysis or Ontarians not receiving dialysis with at least 2 outpatient estimated glomerular filtration rate (eGFR) measurements separated by at least 90 days (maximum 1 year apart). AF was identified using a validated algorithm (sensitivity 80.7%, specificity 99.1%).5 The use of data in this project was authorized under section 45 of Ontario’s Personal Health Information Protection Act, which does not require review by a Research Ethics Board.
The study encompassed the period from January 1, 2011, to December 31, 2022, with January 1 of each calendar year being the index date for all analyses. Individuals meeting AF diagnostic criteria on or before the index date were labeled as having preexisting AF, whereas those meeting diagnostic criteria after the index date were considered newly diagnosed.
Incidence rates of AF per 1,000 person-years (py) and prevalence rates (%) were calculated for each calendar year from 2011 to 2022 by kidney function group (eGFR ≥ 60 mL/min/1.73 m2; eGFR < 60 mL/min/1.73 m2 [ie, nondialysis CKD {ND-CKD}, hemodialysis [HD], and peritoneal dialysis [PD]). Linear trends in incidence rates and prevalence were evaluated by the Cochran-Armitage test. A single-tailed P value < 0.05 was statistically significant.
Analyses were performed using SAS, version 9.4 (SAS Institute).
Results
Between 2011 and 2022, among a total sample size of 19,857,773, there were 109,169 (0.6%), 53,527 (2.2%), 3,427 (4.5%), and 888 (4.3%) new AF diagnoses among individuals without CKD, with ND-CKD, and those receiving HD and PD, respectively. The incidence rate of AF significantly decreased from 24.3 (95% CI 23.5-25.2) in 2011 to 20.7 (95% CI 20.2-21.3) (P < 0.0001) among individuals with ND-CKD. There was no significant change in the incidence rate of AF among HD and PD recipients (Fig 1). The prevalence of AF among individuals with ND-CKD and those receiving dialysis remained stable over the same time (Fig 2). Individuals with underlying CKD had markedly higher incidence rates and prevalence of AF than those without CKD (Figs 1 and 2).
Figure 1.
Incidence rate of atrial fibrillation among individuals with and without chronic kidney disease and dialysis recipients between 2011 and 2022 in Ontario, Canada. There was a statistically significant decrease in the incidence of nondialysis chronic kidney disease. ∗Statistically significant decrease (P < 0.005). Abbreviations: eGFR, estimated glomerular filtration rate; HD, hemodialysis; ND-CKD, nondialysis chronic kidney disease; PD, peritoneal dialysis.
Figure 2.
Prevalence of atrial fibrillation among individuals with and without chronic kidney disease and dialysis recipients between 2011 and 2022 in Ontario, Canada. There was no statistically significant change among any group. Abbreviations: eGFR, estimated glomerular filtration rate; HD, hemodialysis; ND-CKD, nondialysis chronic kidney disease; PD, peritoneal dialysis.
Discussion
We found significant differences in the burden of AF between 2011 and 2022 across kidney function groups. Individuals with CKD, particularly those receiving dialysis, had a higher incidence and prevalence of AF compared with individuals with preserved kidney function. This reinforces the well-established link between chronic kidney disease and increased risk for AF6, which is likely driven by shared risk factors including hypertension, structural heart disease, and metabolic disturbances.7
Among individuals with ND-CKD, there was a statistically significant decline in the incidence of AF over the study, which suggests improvement in cardiovascular risk factor management, earlier CKD detection, and greater use of cardioprotective therapies such as sodium–glucose cotransporter 2 inhibitors inhibitors.8 In contrast, the incidence of AF among individuals receiving dialysis (HD and PD) remained largely unchanged. This trend may reflect the persistent high-risk cardiovascular profile of this cohort where AF is a consequence of irreversible myocardial modeling from chronic volume overload and constant inflammatory stress.7 However, the incidence of AF among individuals receiving PD was more unpredictable than those receiving HD, possibly because of a smaller sample size or changes in population characteristics.
In contrast, the prevalence of AF remained relatively stable among all kidney function groups. It remained consistently highest among individuals with ND-CKD and HD, exceeding 13% across the study, whereas the prevalence among individuals with normal kidney function remained low and stable (∼3%-4%). This contrast and prevalence highlights the disproportionate burden of AF in individuals with more impaired levels of kidney function.9 The relatively stable prevalence of AF despite a modest decline in incidence among individuals with ND-CKD may reflect improved survival or longer disease duration with AF.
During the coronavirus disease-19 pandemic (2020-2022), AF incidence and prevalence remained stable across all kidney function groups. However, the previously declining trend in ND-CKD plateaued, possibly because of reduced outpatient care and diagnostic disruptions during this period.10 In contrast to the changing incidence, the prevalence of AF remained relatively stable across all kidney function groups.
Key strengths of this study include its large sample size and the use of a validated AF case definition with high specificity. However, several limitations should be considered. First, AF diagnoses were based on administrative data and may miss undiagnosed or subclinical cases, particularly during the coronavirus disease-19 pandemic. Second, we were unable to account for individual-level variables (eg, medication use, comorbid condition burden, etc), which could influence AF risk and detection. Third, year-to-year fluctuations in the smaller PD cohort may reflect underlying sample size variability rather than true shifts in AF burden.
Our findings highlight the need for targeted AF prevention strategies across the spectrum of kidney function.
Article Information
Authors’ Contributions
Research idea and study design: SLW, KS, NJ, KG, RW, ZH; data acquisition: NJ, KS, KG; data analysis/interpretation: SLW, KG, RW, ZH; statistical analysis: KG; supervision or mentorship: RW, ZH. Each author contributed important intellectual content during article drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved.
Support
This study was conducted under the auspices of the ICES Kidney Dialysis Transplantation Program at ICES Western who are supported by a grant from the Canadian Institutes of Health Research (CIHR). ICES is funded by an annual grant from the Ontario Ministry of Health (MOH) and Ministry of Long-Term Care (MLTC). Core funding for ICES Western is provided by the Academic Medical Organization of Southwestern Ontario (AMOSO), the Schulich School of Medicine and Dentistry (SSMD), Western University, and the Lawson Health Research Institute (LHRI). Parts of this material are based on data and information compiled and provided by MOH, MLTC, CIHI, and Ontario Health (OH). However, the analyses, conclusions, opinions, and statements expressed herein are solely those of the authors, and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred. The funders had no role in in study design; data collection, analysis, or reporting; or the decision to submit for publication. This sOM Conversion File, which is based on data licensed from Canada Post Corporation, and/or data adapted from the Ontario Ministry of Health Postal Code Conversion File, which contains data copied under license from Canada Post Corporation and Statistics Canada. We thank IQVIA Solutions Canada Inc for use of their Drug Information File.
Financial Disclosure
The authors declare that they have no relevant financial interests.
Peer Review
Received March 15, 2025. Evaluated by 1 external peer reviewer, with direct editorial input from the Statistical Editor, an Associate Editor, and the Editor-in-Chief. Accepted in revised form October 7, 2025.
Footnotes
Complete author and article information provided before references.
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