Absolute risk and risk factors for stroke mortality in patients with end-stage kidney disease (ESKD): population-based cohort study using data linkage

Abstract

IntroductionPeople with end-stage kidney disease (ESKD) have up to 30-fold higher risk of stroke than the general population.ObjectiveTo determine risk factors associated with stroke death in the ESKD population.MethodsWe identified all patients with incident ESKD in Australia (1980–2013) and New Zealand (1988–2012) from the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA) registry. We ascertained underlying cause of death from data linkage with national death registries and risk factors from ANZDATA. Using a competing risks multivariable regression model, we estimated cumulative incidence of stroke and non-stroke deaths, and risk factors for stroke deaths (adjusted sub-HR, SHR).ResultsWe included 60 823 people with ESKD. There were 941 stroke deaths and 33 377 non-stroke deaths during 381 874 person-years of follow-up. Overall, the cumulative incidence of stroke death was 0.9% and non-stroke death was 36.8% 5 years after starting ESKD treatment. The risk of stroke death was higher at older ages (SHR 1.92, 95% CI 1.45 to 2.55), in females (SHR 1.41, 95% CI 1.21 to 1.64), in people with cerebrovascular disease (SHR 2.39, 95% CI 1.99 to 2.87), with ESKD caused by hypertensive/renovascular disease (SHR 1.39, 95% CI 1.09 to 1.78) or polycystic kidney disease (SHR 1.38, 95% CI 1.00 to 1.90), with earlier year of ESKD treatment initiation (SHR 1.93, 95% CI 1.56 to 2.39) and receiving dialysis (transplant vs haemodialysis SHR 0.27, 95% CI 0.09 to 0.84).ConclusionPatients with ESKD with higher risk of stroke death are older, women, with cerebrovascular disease, with hypertensive/renovascular or polycystic kidney disease cause of ESKD, with earlier year of ESKD treatment and receiving dialysis. These groups may benefit from targeted stroke prevention interventions.

Epidemiology of cardiovascular death in kidney failure: An Australian and New Zealand cohort study using data linkage

“…In particular, cardiovascular disease is associated with the highest elevation in mortality risk within the first 120 days from haemodialysis 19 . Sub‐cause analysis of subarachnoid haemorrhages, intracerebral haemorrhages, intracranial haemorrhages and ischaemic strokes have previously been studied and reveal similar trends 22,23 . The risk of cardiovascular mortality in dialysis patients may be exacerbated by dialysis‐induced cardiac injury, 24 endothelial dysfunction 25 and oxidative stress 26 in new patients.…”

“… 19 Sub‐cause analysis of subarachnoid haemorrhages, intracerebral haemorrhages, intracranial haemorrhages and ischaemic strokes have previously been studied and reveal similar trends. 22 , 23 The risk of cardiovascular mortality in dialysis patients may be exacerbated by dialysis‐induced cardiac injury, 24 endothelial dysfunction 25 and oxidative stress 26 in new patients. Treatment agents for cardiovascular disease have not been extensively studied in patients with KF, despite differences in disease progression compared to general populations.…”

“…Several risk factors for cardiovascular death in our study, such as older age, female sex and hypertension, have previously been identified as risk factors for cerebrovascular mortality, allowing for identification of high‐risk groups and opportunities for targeted prevention. 22 , 23 Improved awareness of cardiovascular risk in chronic kidney disease may further facilitate intervention research aimed at improving risk profile before KF onset.…”

Current Trends Featuring the Bridge Between Stroke and End-Stage Renal Disease: A Review

“…Deaths from stroke and non-stroke causes are enhanced in the old age group, early dialysis initiation, normal body mass index (BMI) than obesity, prior cerebrovascular disease, HD than transplant patients, diabetes, or kidney failure caused by hypertension/renal artery disease than glomerulonephritis/IgA nephropathy. Further analysis showed that for stroke-related deaths, females are at increased risk and for non-stroke deaths low BMI, white race, smoking, coronary artery disease, and renal failure due to glomerulonephritis/IgA nephropathy are risk factors [5]. The risk of stroke mortality is more in women and younger age groups [4].…”

“…The risk of hospitalization from ischemic or hemorrhagic stroke is 4-10 times greater with poor long-term prognosis. Increased risk of death from stroke in ESRD patients is seen mainly in women and young people with dialysis initiated early during treatment [4][5][6]. Studies have shown that in patients undergoing dialysis, stroke prevalence is high at the initiation of dialysis with high incidence in the follow-up.…”