Cerebrovascular Disease Incidence, Characteristics, and Outcomes in Patients Initiating Dialysis: The Choices for Healthy Outcomes in Caring for ESRD (CHOICE) Study

Abstract

Background Stroke is the third most common cause of cardiovascular disease death in patients on dialysis; however, characteristics of cerebrovascular disease, including clinical subtypes and subsequent consequences, have not been well described. Study Design Prospective national cohort study, the Choices for Healthy Outcomes in Caring for ESRD (CHOICE) study. Settings & Participants 1,041 incident dialysis patients treated in 81 clinics, enrolled from 10/95–7/98, followed until 12/31/2004. Predictor Time from dialysis initiation. Outcomes & Measurements Cerebrovascular disease events were defined as non-fatal (hospitalized stroke, carotid endarterectomy) and fatal (stroke death) events after dialysis initiation. Stroke subtypes were classified using standardized criteria from the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) system. Incidence of cerebrovascular event subtypes were analyzed using time-to-event analyses accounting for competing risk of death. Clinical outcomes after stroke were abstracted from medical records. Results A total of 165 participants experienced a cerebrovascular event with an overall incidence of 4.9 per 100 person-years. Ischemic stroke was the most common (76% of all 200 events) with cardioembolism subtype accounting for 28% of the 95 abstracted ischemic events. The median time from onset of symptoms to first stroke evaluation was 8.5 hours (25th and 75th percentiles 1, 42 hours), with only 56% of patients successfully escaping death, nursing home, or a skilled nursing facility. Limitations Relatively small sample size limits power to determine risk factors. Conclusions Cerebrovascular disease is common in dialysis patients, is identified late, and carries a significant risk of morbidity and mortality. Stroke etiologic subtypes on dialysis are multifactorial, suggesting risk factors may change the longer one has ESRD. Further studies are needed to address the poor prognosis through prevention, early identification, and treatment.

Stroke and the “Stroke Belt” in Dialysis

“…Relatively few studies have explicitly examined factors associated with ischemic strokes. As with our study, most investigators [15][16][17] (but not all 18 ) show age to be a significant risk factor associated with stroke, a finding that would be expected from the general population. The role of sex has been less fully explored; one study showed no association between sex and stroke, 15 whereas another suggested a trend in which female sex was associated with stroke.…”

“…The role of sex has been less fully explored; one study showed no association between sex and stroke, 15 whereas another suggested a trend in which female sex was associated with stroke. 16 The role of race is yet more difficult to characterize: Seliger et al 15 showed that African American race was associated with new strokes (ischemic and hemorrhagic combined) only in the setting of previously established cardiovascular disease; in individuals without preexisting disease, African America race was associated with lower stroke rates. Sozio et al 16 also showed that African American race was inversely associated with stroke risk.…”

Inflammatory Markers and Risk of Cerebrovascular Events in Patients Initiating Dialysis

“…We previously reported that age, race, and comorbidity were some of the strongest risk factors for stroke in the dialysis population (14), and a study by Tripepi et al BP, and cardiac function (5) have the potential to account for some of the additional increased stroke risk in this population. Hypertension is highly prevalent in dialysis patients, but only 30% are adequately controlled (33).…”

“…The primary outcome of this ancillary investigation was the first cerebrovascular event after dialysis initiation, including ischemic stroke, hemorrhagic stroke, or carotid endarterectomy. Assignment of cerebrovascular events in CHOICE has been described previously (14), and was based primarily upon review of adjudicated records by a Cardiovascular Disease Endpoints committee.…”

Temporal Trends in the Outcomes of Dialysis Patients Admitted With Acute Ischemic Stroke

“…In their study, patients on dialysis had significantly higher odds of experiencing AIS than non‐dialysis patients (odd ratio 6.1, and 10.1 for white males and females and 4.3 and 6.5 for black males and females, P <0.001 for all). Other studies investigating the incidence of AIS in dialysis patients were single center, non‐contemporary or primarily involved non‐US population 2, 8, 16, 17, 18. To our knowledge, this is the largest study examining contemporary rates of AIS in the dialysis and non‐dialysis population.…”