Evidence for the Prevention and Treatment of Stroke in Dialysis Patients

Abstract

The risks of both ischemic and hemorrhagic stroke are particularly high in dialysis patients of any age and outcomes are poor. It is therefore important to identify strategies that safely minimize stroke risk in this population. Observational studies have been unable to clarify the relative importance of traditional stroke risk factors such as blood pressure and cholesterol in those on dialysis, and are affected by biases that usually make them an inappropriate source of data on which to base therapeutic decisions. Well-conducted randomized trials are not susceptible to such biases and can reliably investigate the causal nature of the association between a potential risk factor and the outcome of interest. However, dialysis patients have been under-represented in the cardiovascular trials which have proven net benefit of commonly used preventative treatments (e.g., antihypertensive treatments, low-dose aspirin, carotid revascularization, and thromboprophylaxis for atrial fibrillation), and there remains uncertainty about safety and efficacy of many of these treatments in this high-risk population. Moreover, the efficacy of renal-specific therapies that might reduce cardiovascular risk, such as modulators of mineral and bone disorder, online hemodiafiltration, and daily (nocturnal) hemodialysis, have not been tested in adequately powered trials. Recent trials have also demonstrated how widespread current practices could be causing stroke. Therefore, it is important that reliable information on the prevention and treatment of stroke (and other cardiovascular disease) in dialysis patients is generated by performing large-scale randomized trials of many current and future treatments.

Association Between Serum Phosphate Levels and Stroke Risk in Patients Undergoing Hemodialysis

“…Male sex, history of cardiovascular events, higher systolic blood pressure, and lower hemoglobin levels were associated with increased brain hemorrhage risk, consistent with previous reports. 3,[7][8][9][10] Similarly, the identified associations of older age and history of cardiovascular events with increased risk of brain infarction were consistent with previous observations. 3,[7][8][9] However, the mechanisms whereby lower serum PTH levels and higher normalized protein catabolic rate enhance the risk of brain infarction remain unclear.…”

“…[1][2][3][4] The risk of stroke is increased in patients with CKD, 3,4 and CKD patients, especially those undergoing hemodialysis, are at increased risks of hospitalization, disability, and death after stroke, which are associated with a negative impact on society. [5][6][7] Although previous studies have identified traditional and nontraditional risk factors for stroke in hemodialysis patients, the incidence of stroke still remains unacceptably high.…”

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

“…This percentage is higher than the percentage of black individuals in the overall population, it is indeed proportional to their percentage of black patients among dialysis patients in the United States,13 (2) Dialysis patients experiencing AIS are more likely to be cared for at urban, teaching hospital and to be in the lowest quartile of median household income, (3) Although dialysis patients had higher prevalence of hypertension, diabetes mellitus, coronary and vascular diseases, and heart failure, they had lower prevalence of atrial fibrillation, a major risk factor for AIS. This could be related to the lower incidence of atrial fibrillation among black and Hispanic patients, who together constituted 50% of the AIS dialysis population,20 and (4) Despite the higher prevalence of vascular disease and the higher perceived risk of bleeding among dialysis patients, the utilization of thrombolytic increased proportionally in dialysis and non‐dialysis patients. The utilization rates of mechanical thrombectomy were minuscule in both groups, because these data preceded the published trials demonstrating the significant benefit of thrombectomy in selected AIS patients 21…”

Impact of the Number of Anti-Thrombosis Agents in Hemodialysis Patients: BOREAS-HD2 Study

“…The effect of anti-thrombosis agents on the incidence of ischemic stroke in HD patients is controversial [22]. A notable difference between a study by Olesen et al [23].…”