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

Sozio, Stephen M.; Armstrong, Paige A.; Coresh, Josef; Jaar, Bernard G.; Fink, Nancy E.; Plantinga, Laura C.; Powe, Neil R.; Parekh, Rulan S.

doi:10.1053/j.ajkd.2009.01.261

« Previous Next »American Journal of Kidney Diseases
Volume 54, Issue 3 , Pages 468-477, September 2009

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

Stephen M. Sozio, MD, MHS
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD
- Address correspondence to Stephen M. Sozio, MD, MHS, Johns Hopkins University School of Medicine, Division of Nephrology, 1830 E Monument St, Ste 416; Baltimore, MD 21205
Paige A. Armstrong, MHS
- University of Connecticut School of Medicine, Farmington, CT
Josef Coresh, MD, PhD
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
Bernard G. Jaar, MD, MPH
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD
- Nephrology Center of Maryland, Baltimore, MD
Nancy E. Fink, MPH
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD
Laura C. Plantinga, ScM
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD
Neil R. Powe, MD, MPH, MBA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD
Rulan S. Parekh, MD, MS
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD

Received 10 September 2008; accepted 14 January 2009. published online 20 April 2009.

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.

Index Words: Cerebrovascular disease, stroke, dialysis, prognosis, epidemiology

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.

PII: S0272-6386(09)00432-6

doi:10.1053/j.ajkd.2009.01.261

Refers to article:

Stroke in ESRD: The Other Cardiovascular Disease
Stephen L. Seliger
American Journal of Kidney Diseases September 2009 (Vol. 54, Issue 3, Pages 403-405)
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