First Documented Atrial Fibrillation Triggered by Dialysis-Induced Autonomic Instability in End-Stage Kidney Disease

Atrial fibrillation (AF) is the most common sustained arrhythmia in the general population. However, it is seldom the initial rhythm disturbance in dialysis-dependent patients, who more often present with bradyarrhythmias or ventricular tachyarrhythmias. We report a 59-year-old man with end-stage kidney disease on thrice-weekly hemodialysis who developed his first documented AF with rapid ventricular response immediately after dialysis. Coexisting hypotension, asthma, and severely reduced left ventricular ejection fraction limited the use of β-blockers, calcium channel blockers, and digoxin. Given these limitations, intravenous amiodarone was selected as the most appropriate option, providing both rhythm and partial rate control while maintaining hemodynamic stability, and cautious crystalloid resuscitation was administered, resulting in partial stabilization and intermittent reversion to sinus rhythm. This case illustrates dialysis as a direct arrhythmogenic stressor through autonomic imbalance and electrolyte shifts, with underlying ventricular dysfunction serving as a substrate. It emphasizes the challenges of managing AF when standard therapies are contraindicated and highlights the importance of individualized treatment in dialysis patients with complex comorbidities.