title: Appraising stroke risk in maintenance hemodialysis patients: a large single-center cohort study.
abstract: BACKGROUND
  Stroke incidence in hemodialysis patients is up to 10 times greater than in the general population and is associated with a worse prognosis. Factors influencing stroke risk by subtype and subsequent prognosis are poorly described in the literature.
  
  
  METHODS
  Retrospective single-center cohort study.
  
  
  METHODS
  2,384 established maintenance hemodialysis patients at a single center from January 1, 2002, to June 1, 2009.
  
  
  METHODS
  Patient demographics, comorbid conditions.
  
  
  RESULTS
  Incidence of acute stroke (International Classification of Diseases, 9th Revision codes 430, 431, 432.9, 433.1, and 434.1 with evidence of compatible neuroimaging), patient survival.
  
  
  METHODS
  Cumulative patient survival, incidence of acute fatal and nonfatal stroke.
  
  
  RESULTS
  127 strokes occurred during 9,541 total patient-years of follow-up. First (incident) stroke occurred at a rate of 14.9/1,000 patient years (95% CI, 12.2-17.9) with a predominance of ischemic compared with hemorrhagic subtypes (11.2 vs 3.7/1,000 patient-years). 54% of hemorrhagic strokes occurred in patients of South Asian ethnicity compared with ischemic strokes, which occurred predominantly in white patients (45% of events). Diabetes mellitus (HR, 1.92; 95% CI, 1.29-2.85; P = 0.001) and prior cerebrovascular disease (HR, 4.54; 95% CI, 3.07-6.72; P < 0.001) were independently associated with incident cerebrovascular accident on multivariate analysis. Acute stroke was associated with worse patient survival (HR, 3.26; 95% CI, 2.47-4.30; P < 0.001) and overall 1-year mortality of 24%, which was significantly worse in patients with hemorrhagic events (39% vs 19% mortality for ischemic subtypes). Serum albumin level >3.5 g/L (HR, 0.38; 95% CI, 0.19-0.76; P = 0.007) and C-reactive protein level >3.0 mg/l (HR, 1.36; 95% CI, 1.12-1.64; P = 0.002) influenced survival after stroke on multivariate analysis.
  
  
  CONCLUSIONS
  Retrospective analysis of data cannot prove causality.
  
  
  CONCLUSIONS
  The high incidence of stroke in hemodialysis patients is associated with high mortality, especially hemorrhagic subtypes. Strict management of hypertension, better appreciation of hemodialysis anticoagulation, and large-scale interventional studies are urgently required to direct prevention and treatment of this significant disease.
authors.affiliation: Hemodialysis Research Group, Imperial College Kidney and Transplant Center, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom. albert.power@nhs.net
authors.forename: Albert
authors.initials: A
authors.lastname: Power
authors.forename: Kakit
authors.initials: K
authors.lastname: Chan
authors.forename: Seema K
authors.initials: SK
authors.lastname: Singh
authors.forename: David
authors.initials: D
authors.lastname: Taube
authors.forename: Neill
authors.initials: N
authors.lastname: Duncan
mesh_terms: D000328:Adult; D000368:Aged; D044466:Asian People; D044383:Black People; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D007676:Kidney Failure, Chronic / Q000208:ethnology* / Q000401:mortality / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis; D012189:Retrospective Studies; D012307:Risk Factors; D020521:Stroke / Q000453:epidemiology* / Q000208:ethnology* / Q000401:mortality; D015996:Survival Rate; D006113:United Kingdom; D044465:White People