Relationship between Stroke and Mortality in Dialysis Patients

Abstract

Background and objectives Stroke is common in patients undergoing long-term dialysis, but the implications for mortality after stroke in these patients are not fully understood.Design, setting, participants, & measurements A large cohort of dually-eligible (Medicare and Medicaid) patients initiating dialysis from 2000 to 2005 and surviving the first 90 days was constructed. Medicare claims were used to ascertain ischemic and hemorrhagic strokes occurring after 90-day survival. A semi-Markov model with additive hazard extension was generated to estimate the association between stroke and mortality, to calculate years of life lost after a stroke, and to determine whether race was associated with differential survival after stroke.Results The cohort consisted of 69,371 individuals representing .112,000 person-years of follow-up. Mean age6SD was 60.8615.5 years. There were 21.1 (99% confidence interval [99% CI], 20.0 to 22.3) ischemic strokes and 4.7 (99% CI, 4.2 to 5.3) hemorrhagic strokes after cohort entry per 1000 patient-years. At 30 days, mortality was 17.9% for ischemic stroke and 53.4% for hemorrhagic stroke. The adjusted hazard ratio (AHR) depended on time since entry into the cohort; for patients who experienced a stroke at 1 year after cohort entry, for example, the AHR of hemorrhagic stroke for mortality was 25.4 (99% CI, 22.4 to 28.4) at 1 week, 9.9 (99% CI, 8.4 to 11.6) at 3 months, 5.9 (99% CI, 5.0 to 7.0) at 6 months, and 1.8 (99% CI, 1.5 to 2.1) at 24 months. The corresponding AHRs for ischemic stroke were 11.7 (99% CI, 10.2 to 13.1) at 1 week, 6.6 (99% CI, 6.4 to 6.7) at 3 months, and 4.7 (99% CI, 4.5 to 4.9) at 6 months, remaining significantly .1.0 even at 48 months. Median months of life lost were 40.7 for hemorrhagic stroke and 34.6 for ischemic stroke. For both stroke types, mortality did not differ by race.Conclusions Dialysis recipients have high mortality after a stroke with corresponding decrements in remaining years of life. Poststroke mortality does not differ by race.

Long-Term Survivor Characteristics in Hemodialysis Patients with Type 2 Diabetes

“…The association of PVD with mortality was stronger in patients with first diagnosis of diabetes mellitus more than 18 years ago possibly reflecting complications of the diabetic foot syndrome. Interestingly, CeVD at baseline was not associated with higher mortality risk, even though for example Wetmore et al[23] report a loss of months of life for hemorrhagic (40.7 months) as well as ischemic stroke (34.6 months) patients. This might have been influenced by the fact that CeVD at baseline was defined as stroke or transitory ischemic attack.…”

“…Furthermore, patient selection before study entry might have played a role, too. According to a study by Wetmore et al [23], mortality after acute stroke is highest within the first 6 months and decreases steadily until at least 48 months. If patients more than 48 months after stroke were recruited into the 4D study, the mortality risk might be nearly the same as in patients without previous stroke.…”

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

“…[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. [8][9][10][11] Increasing evidence suggests that CKD-related bone-mineral disorders are an important nontraditional risk factor for cardiovascular morbidity and mortality in CKD patients.…”

Strategies for the Super-Aged Dialysis Population: Survival Benefits or Alternative Goals?

“…Cerebrovascular Disease According to the Choices for Healthy Outcomes in Caring for ESRD (CHOICE) study, a cerebrovascular event with an overall incidence of 4.9 per 100 personyears and ischemic stroke were the most common for patients on dialysis (76% of all 200 events) [31]. Data from a large cohort in the United States revealed that hemorrhagic stroke survival is worse than that following ischemic stroke [32].…”