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

doi:10.1053/j.ajkd.2009.01.261

American Journal of Kidney Diseases

Volume 54, Issue 3, September 2009, Pages 468-477

https://doi.org/10.1053/j.ajkd.2009.01.261 Get rights and content

Background

Stroke is the third most common cause of cardiovascular disease death in patients on dialysis therapy; 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 End-Stage Renal Disease (CHOICE) Study.

Settings & Participants

1,041 incident dialysis patients treated in 81 clinics enrolled from October 1995 to July 1998, followed up until December 31, 2004.

Predictor

Time from dialysis therapy initiation.

Outcomes & Measurements

Cerebrovascular disease events were defined as nonfatal (hospitalized stroke and carotid endarterectomy) and fatal (stroke death) events after dialysis therapy initiation. Stroke subtypes were classified by using standardized criteria from the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) system. The incidence of cerebrovascular event subtypes was analyzed by using time-to-event analyses accounting for competing risk of death. Clinical outcomes after stroke were abstracted from medical records.

Results

165 participants experienced a cerebrovascular event with an overall incidence of 4.9 events/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. Median time from onset of symptoms to first stroke evaluation was 8.5 hours (25th and 75th percentiles, 1 and 42), with only 56% of patients successfully escaping death, nursing home, or 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 therapy are multifactorial, suggesting risk factors may change the longer one has end-stage renal disease. Additional studies are needed to address the poor prognosis through prevention, early identification, and treatment.

Section snippets

Study Design

Study participants were from the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease (CHOICE) Study.⁹ This national prospective cohort study of incident dialysis patients was initiated in 1995 to investigate treatment choices and clinical outcomes in dialysis care. Eligibility criteria for enrollment in CHOICE included new onset of long-term dialysis therapy in the preceding 3 months, ability to provide informed consent, age 18 years or older, and ability to speak English or

Results

Approximately two-thirds of eligible patients were enrolled in CHOICE from participating dialysis units. Eligible patients enrolled were similar to eligible, but unenrolled, patients with regard to age, sex, dialysis modality, albumin level, and blood pressure. Baseline characteristics of the 1,041 CHOICE participants are listed in Table 1. Age, sex, race, and dialysis modality distributions were similar to those of the 1997 US dialysis population, as described previously.¹⁶ During a median

Discussion

In this national prospective cohort study of patients initiating dialysis therapy for end-stage renal disease, cerebrovascular events, including fatal and nonfatal clinical stroke and CEA, occurred 10 times more frequently than in the general population,8, 17 with an incidence rate of 4.9 events/100 person-years. The majority of events were related to ischemic stroke, with cardioembolic stroke the most common form of ischemic stroke in dialysis patients. To our knowledge, this is 1 of the first

Acknowledgements

We thank the patients, staff, laboratory, and medical directors of the participating clinics at DCI, New Haven CAPD, and St Raphael's Hospital who contributed to the study. We thank members of the Cardiovascular Endpoint Committee: Michael J. Choi, MD; Joseph A. Eustace, MD, MHS; Caroline Fox, MD, MPH; Melanie H. Katzman, MD, MHS; Michael J. Klag, MD, MPH; Yongmei Liu, MD, PhD; J. Craig Longenecker, MD, PhD; Michal Melamed, MD, MHS; Renuka Sothinathan, MD, MHS; Richard M. Ugarte, MD, MHS; and

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Ischemic stroke in CKD4-5.
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123,251 patients with CKD4 and 22,054 with CKD5 were identified. Mean ages were 81.0 and 79.2 years, respectively. Female sex (HRs of 1.21 [95% CI, 1.12-1.31] and 1.39 [95% CI, 1.04-1.86] for CKD4 and CKD5, respectively) and black race (HRs of 1.25 [95% CI, 1.12-1.39] and 1.12 [95% CI, 0.80-1.58] for CKD4 and CKD5, respectively) were factors associated with ischemic stroke. Rates for 30-day mortality were 13.3% and 18.8%, and for 1-year mortality, 40.0% and 38.2%. For patients with CKD5, kidney failure or death occurred an average of 3.6 months sooner for patients with an ischemic stroke, and death (irrespective of kidney failure), a mean of 24.3 months sooner.
Study design cannot determine causality; lack of data for stroke severity.
Female sex and black race were associated with increased risk for stroke in CKD4 and CKD5. In CKD5, stroke was associated with a shorter time to kidney failure or death by nearly 4 months, and to death, by more than 2 years.
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: Originally published online as doi: 10.1053/j.ajkd.2009.01.261 on April 20, 2009.

: Because the Editor-in-Chief recused himself from consideration of this manuscript, the Deputy Editor (Daniel E. Weiner, MD, MS) served as Acting Editor-in-Chief. Details of the journal's procedures for potential editor conflicts are given in the Editorial Policies section of the AJKD website.

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

Background

Study Design

Settings & Participants

Predictor

Outcomes & Measurements

Results

Limitations

Conclusions

Section snippets

Study Design

Results

Discussion

Acknowledgements

Kidney Int

Kidney Int

Am J Kidney Dis

Lancet Neurol

Am J Kidney Dis

Lancet

Am J Kidney Dis

Am J Kidney Dis

Kidney Int

USRDS 2007 Annual Data ReportAtlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States

Silent cerebral infarction in hemodialysis patients

Am J Nephrol

Mineral metabolism, mortality, and morbidity in maintenance hemodialysis

J Am Soc Nephrol

Stroke

Choices for Healthy Outcomes In Caring for End Stage Renal Disease

Semin Dial

Relationship of C-reactive protein to risk of cardiovascular disease in the elderlyResults from the Cardiovascular Health Study and the Rural Health Promotion Project

Arterioscler Thromb Vasc Biol

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