Acute Kidney Injury, Atrial Fibrillation (AF)
Conditions
Keywords
Pulsed field ablation, Atrial Fibrillation, Acute kidney injury, Hydration
Brief summary
PFA is an emerging non-thermal ablation technology with favorable procedural safety; however, recent studies have raised concerns about peri-procedural hemolysis and subsequent AKI after PFA. This study is a single-center, open-label, randomized controlled trial designed to evaluate whether standardized peri-procedural intravenous hydration can reduce the risk of acute kidney injury (AKI) after pulsed field ablation (PFA) for atrial fibrillation (AF). Eligible adult patients with symptomatic paroxysmal or persistent AF scheduled for PFA will be randomly assigned in a 1:1 ratio to either a standardized hydration strategy or a control strategy without routine prophylactic hydration. The hydration group will receive 0.9% saline at 2 mL/kg/h from entry into the electrophysiology laboratory until 12 hours after the procedure, while the control group will receive no routine preventive hydration and will be treated with fluids only if clinically indicated. The primary outcome is any in-hospital AKI defined according to Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Secondary endpoints include in-hospital AKI severity by KDIGO stage, in-hospital persistent moderate-to-severe AKI, in-hospital renal replacement therapy, changes in renal function after the procedure, and clinical outcomes through 30 and 90 days, including all-cause death, persistent AKI, renal replacement therapy, all-cause rehospitalization, and composite major adverse events.
Detailed description
Pulsed field ablation (PFA) has rapidly emerged as a promising non-thermal catheter ablation technology for the treatment of atrial fibrillation (AF). Although its overall safety profile appears favorable, increasing evidence suggests that peri-procedural hemolysis may occur after PFA. In some patients, this hemolysis may contribute to acute kidney injury (AKI), which has become an important safety concern in contemporary PFA practice. Peri-procedural hydration may represent a practical kidney-protective strategy by maintaining renal perfusion and promoting clearance of hemolysis-related pigments and other nephrotoxic factors. However, no randomized controlled trial has evaluated whether routine standardized hydration reduces the risk of AKI after AF ablation with PFA. The HYDRATE-PFA trial is a single-center, open-label, superiority, parallel-group randomized controlled trial designed to assess whether a standardized peri-procedural hydration strategy can reduce the risk of AKI after PFA for AF. A total of 290 adult patients with symptomatic paroxysmal or persistent AF who are scheduled to undergo PFA will be enrolled at Beijing Anzhen Hospital, Capital Medical University. Participants will be randomized in a 1:1 ratio to either a standardized peri-procedural hydration group, or a control group without routine prophylactic hydration. Participants assigned to the hydration group will receive 0.9% sodium chloride intravenously at 2 mL/kg/h starting when the participant enters the electrophysiology laboratory and continuing until 12 hours after the procedure. The infusion rate may be reduced or interrupted if there is evidence of fluid overload, hypoxemia, pulmonary congestion, or any other safety concern judged by the investigator. Participants assigned to the control group will not receive routine preventive hydration; intravenous fluids may be given only when clinically indicated, such as for suspected hemoglobinuria, rising serum creatinine, oliguria. For all participants, blood and urine samples will be collected at baseline, immediately after the procedure, and 24 hours after the procedure, with additional in-hospital testing if clinically indicated. Participants will also be followed at 30 days and 90 days after randomization by clinic visit or telephone contact. The primary endpoint is any in-hospital AKI, defined according to KDIGO criteria (an increase in serum creatinine of at least 0.3 mg/dL within 48 hours or an increase to at least 1.5 times baseline). Secondary endpoints include in-hospital AKI severity by KDIGO stage, in-hospital persistent moderate-to-severe AKI, in-hospital renal replacement therapy, changes in renal function after the procedure, and clinical outcomes through 30 and 90 days, including all-cause death, persistent AKI, renal replacement therapy, all-cause rehospitalization, and composite major adverse events.
Interventions
DRUG0.9% sodium chloride
Participants assigned to the hydration group will receive 0.9% sodium chloride intravenously at 2 mL/kg/h starting when the participant enters the electrophysiology laboratory and continuing until 12 hours after the procedure. The infusion rate may be reduced or interrupted if there is evidence of fluid overload, hypoxemia, pulmonary congestion, or any other safety concern judged by the investigator.
Sponsors
Beijing Anzhen Hospital
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
SINGLE (Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
Participants must meet all of the following criteria: * Age ≥18 years. * Symptomatic paroxysmal atrial fibrillation (AF) or persistent AF: 1. Paroxysmal AF: AF that terminates spontaneously or with intervention within 7 days of onset, and meets both of the following: 1. At least 2 symptomatic paroxysmal AF episodes within 6 months before enrollment; 2. At least 1 documented AF episode by electrocardiogram (ECG) or Holter monitoring within 12 months before enrollment. 2. Persistent AF: AF lasting \>7 days and ≤365 days, and meets both of the following: 1. At least 1 symptomatic persistent AF episode within 6 months before enrollment; 2. Persistent AF documented within 12 months before enrollment by either Holter monitoring or 2 ECGs obtained at least 7 days apart. * Failure of antiarrhythmic drug (AAD) therapy, defined as inadequate efficacy and/or intolerance to at least 1 Class I or Class III AAD. * Planned to undergo pulsed field ablation (PFA). * Willing and able to provide written informed consent. * Willing and able to comply with study procedures, including in-hospital assessments and 30-day and 90-day follow-up.
Exclusion criteria
Participants meeting any of the following criteria will be excluded: * AF due to a reversible cause, such as hyperthyroidism or perioperative/cardiothoracic surgery-related AF. * No oral anticoagulation for at least 3 weeks before ablation. * Intracardiac thrombus. * Contraindication to anticoagulant therapy or iodinated contrast media. * Significant valvular heart disease, including moderate or severe aortic stenosis, severe aortic regurgitation, moderate or severe mitral stenosis, or severe mitral regurgitation. * Myocardial infarction within 3 months before enrollment. * Cardiac surgery within 3 months before enrollment. * New York Heart Association (NYHA) class III or IV congestive heart failure. * Left ventricular ejection fraction (LVEF) \<35%. * Hypertrophic cardiomyopathy. * Severe liver disease (Child-Pugh score \>7). * Stage 4 or 5 chronic kidney disease (eGFR \<30 mL/min/1.73 m²). * History of kidney transplantation. * Need for renal replacement therapy (RRT) at enrollment or any history of prior RRT. * Intravascular iodinated contrast administration within 7 days before enrollment. * Active systemic infection. * Known pregnancy or breastfeeding. * Participation in another clinical trial that may affect the results of this study. * Unwillingness or inability to comply with study procedures and follow-up, including participants considered by the investigator to be at substantial risk for poor adherence.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| In-hospital acute kidney injury | Periprocedural | Acute kidney injury (AKI) of any severity during hospitalization, meeting any of the following criteria according to KDIGO guidelines: 1) an increase in serum creatinine level of 0.3 mg/dL within 48 hours, or 2) an increase to at least 1.5 times baseline. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| In-hospital AKI severity | Periprocedural | AKI Severity (defined by KDIGO staging): * Stage 1 AKI: Serum creatinine increase ≥0.3 mg/dL or reaching 1.5-1.9 times baseline; * Stage 2 AKI: Serum creatinine reaches 2.0-2.9 times baseline; * Stage 3 AKI: Serum creatinine (SCr) reaches ≥3.0 times baseline, or SCr ≥4.0 mg/dL (≥353.6 μmol/L), or initiation of renal replacement therapy (RRT). |
| In-hospital persistent moderate-to-severe AKI | Periprocedural | Persistent moderate-to-severe AKI during hospitalization is defined as KDIGO stage 2-3 AKI lasting ≥48 hours. AKI staging defined by KDIGO guideline: * Stage 1 AKI: Serum creatinine increase ≥0.3 mg/dL or reaching 1.5-1.9 times baseline; * Stage 2 AKI: Serum creatinine reaches 2.0-2.9 times baseline; * Stage 3 AKI: Serum creatinine (SCr) reaches ≥3.0 times baseline, or SCr ≥4.0 mg/dL (≥353.6 μmol/L), or initiation of renal replacement therapy (RRT). |
| In-hospital renal replacement therapy | Periprocedural | In-hospital renal replacement therapy (RRT) is defined as the initiation of RRT for any reason during hospitalization. |
| Absolute and relative changes in serum creatinine and eGFR after the procedure | Periprocedural | Absolute and relative changes in serum creatinine and eGFR from baseline to immediately after the procedure and 24 hours after the procedure. |
| 30-day mortality | Within 30 days after randomization | — |
| 30-day persistent AKI | Within 30 days after randomization | Defined as a serum creatinine level remaining at least 50% higher than the pre-procedure baseline value at 30 days after randomization. |
| 30-day renal replacement therapy | Within 30 days after randomization | — |
| 30-day all-cause rehospitalization | Within 30 days after randomization | — |
| 30-day composite major adverse events | Within 30 days after randomization | Composite of all-cause death, persistent AKI, initiation of RRT, or all-cause rehospitalization within 30 days after randomization. |
| 90-day mortality | Within 90 days after randomization | — |
| 90-day persistent AKI | Within 90 days after randomization | Defined as a serum creatinine level remaining at least 50% higher than the pre-procedure baseline value at 90 days after randomization. |
| 90-day renal replacement therapy | Within 90 days after randomization | — |
| 90-day all-cause rehospitalization | Within 90 days after randomization | — |
| 90-day composite major adverse events | Within 90 days after randomization | Composite of all-cause death, persistent AKI, initiation of RRT, or all-cause rehospitalization within 90 days after randomization. |
Countries
China
Outcome results
None listed