Association of kidney disease measures with ischemic versus hemorrhagic strokes: pooled analyses of 4 prospective community-based cohorts

Association between Urine Albumin-to-creatinine Ratio and Intracranial Atherosclerotic Plaque in Chinese Adults - Results from the PRECISE Study

AIMS

Intracranial plaque may cause stroke in the absence of luminal stenosis. Although urine albumin-to-creatinine ratio (ACR) has been proved an established risk factor for cardiovascular disease, stroke and carotid atherosclerosis, little is known on the relationship between urine ACR and intracranial plaque.

METHODS

Subjects with history of stroke or coronary heart disease (CHD) were excluded in the PRECISE study. The intracranial plaque was assessed by vessel wall magnetic resonance imaging (MRI). Subjects were stratified according to ACR tertiles. Logistic regression and ordinal regression were performed to analyze the association between ACR and the presence of intracranial plaque or sum of the stenosis score for each artery.

RESULTS

2962 individuals were included with the mean age of 61.0±6.6 years. The median ACR was 11.7mg/g (interquartile range 7.0-22.0 mg/g), and the mean estimated glomerular filtration rate (eGFR) based on combination of creatinine and cystatin C was 88.5±14.8 ml/min·1.73m2. 495 (16.7%) participants had intracranial plaque. The highest ACR tertile with ACR ＞16.00mg/g was independently associated with the presence of intracranial plaque (OR 1.38, 95% CI: 1.05-1.82, p=0.02) and the odds of higher intracranial plaque burden (common OR 1.39, 95% CI: 1.05-1.83, p=0.02) after adjustment of confounding factors. No significant association was observed between eGFR and intracranial plaque presence or intracranial plaque burden.

CONCLUSIONS

Among a low-risk community-dwelling population without prior stroke or CHD in China, ACR was independently associated with intracranial plaque presence and plaque burden measured by vessel wall MRI.

Cystatin C-based estimated glomerular filtration rate and risk of stroke in the general population: a prospective cohort study

Background

Previous results on the association between the estimated glomerular filtration rate (eGFR) and stroke are mixed. Most studies derived the eGFR from serum creatinine, which is affected by non-kidney determinants and thus has possibly biased the association with stroke risk.

Methods

In this cohort study, we included 429 566 UK Biobank participants (94.5% white, 54% women, age 56 ± 8 years) free of stroke at enrollment. The eGFRcys and eGFRcr were calculated with serum cystatin C and creatinine, respectively. Outcomes of interest were risk of total stroke and subtypes. We investigated the linear and nonlinear associations using Cox proportional hazards models and restricted cubic splines, corrected for regression dilution bias.

Results

During an average follow-up of 10.11 years, 4427 incident strokes occurred, among which 3447 were ischemic and 1163 were hemorrhagic. After adjustment for confounders, the regression dilution-corrected hazard ratios (95% confidence intervals) for every 10 mL/min/1.73 m2 decrement in eGFRcys were 1.10 (1.05-1.14) for total stroke and 1.11 (1.08-1.15) for ischemic stroke. A similar pattern was observed with eGFRcr, although the association was weaker. When either type of eGFR was below 75 mL/min/1.73 m2, the risks of total and ischemic stroke increased exponentially as eGFR decreased. A U-shaped relationship was witnessed if eGFRcr was used instead. There was a null association between eGFR and hemorrhagic stroke.

Conclusions

The risks of total stroke and ischemic stroke increased exponentially when the eGFRcys fell below 75 mL/min/1.73 m2.

Relationship between Kidney Dysfunction, Stroke Severity, and Outcomes in a Nigerian Tertiary Hospital: A Prospective Study

BACKGROUND

Stroke is a common neurologic disease associated with fatal outcomes. Kidney dysfunction may be an important predictor of stroke severity and outcome.

AIM

To determine the relationship between kidney dysfunction at admission and stroke severity and 30-day outcome.

MATERIALS AND METHODS

This was a prospective study that involved 150 stroke patients. Stroke severity at admission was assessed using the National Institutes of Health Stroke Scale (NIHSS). Renal dysfunction was assessed by the presence of albuminuria and or reduced glomerular filtration rate (GFR) at admission. Neurological outcome was assessed using mortality, modified Rankin Scale (mRS), and Glasgow Outcome Scale (GCS).

RESULTS

The mean age of the study participants was 61.0 ± 13.2 years. Renal dysfunction was present in 66% of the participants while the case fatality rate of stroke was 26%. Poor neurological outcome at 30 days was found in 44.1% of survivors. Those with albuminuria had lower GCS (P = 0.041), lower GFR (P = 0.004), higher mRS score on day 14 (P = 0.041) and day 30 (P = 0.032), and higher NIHSS score (P = 0.034). Independent predictors of 30-day mortality were albuminuria (Adjusted Odd Ratio (AOR) 3.60, 95%CI: 1.07-12.17) and increasing NIHSS score (AOR = 1.15, 95%CI: 1.04-1.28). Lower GCS (P < 0.001), elevated white blood cells (P = 0.003), serum creatinine (P = 0.048), and NIHSS score (P < 0.001) were associated with poor neurological outcome. NIHSS score was the only significant predictor of neurologic outcome (AOR: 1.25; CI: 1.11-1.41; P ≤ 0.001).

CONCLUSIONS

Kidney dysfunction was associated with stroke severity and mortality. However, it was not an independent predictor of neurological outcome.

Evaluation of plasma sphingolipids as mediators of the relationship between kidney disease and cardiovascular events

BACKGROUND

Sphingolipids are a family of circulating lipids with regulatory and signaling roles that are strongly associated with both eGFR and cardiovascular disease. Patients with chronic kidney disease (CKD) are at high risk for cardiovascular events, and have different plasma concentrations of certain plasma sphingolipids compared to patients with normal kidney function. We hypothesize that circulating sphingolipids partially mediate the associations between eGFR and cardiovascular events.

METHODS

We measured the circulating concentrations of 8 sphingolipids, including 4 ceramides and 4 sphingomyelins with the fatty acids 16:0, 20:0, 22:0, and 24:0, in plasma from 3,463 participants in a population-based cohort (Cardiovascular Health Study) without prevalent cardiovascular disease. We tested the adjusted mediation effects by these sphingolipids of the associations between eGFR and incident cardiovascular disease via quasi-Bayesian Monte Carlo method with 2,000 simulations, using a Bonferroni correction for significance.

FINDINGS

The mean (±SD) eGFR was 70 (±16) mL/min/1.73 m2; 62% of participants were women. Lower eGFR was associated with higher plasma ceramide-16:0 and sphingomyelin-16:0, and lower ceramides and sphingomyelins-20:0 and -22:0. Lower eGFR was associated with risk of incident heart failure and ischemic stroke, but not myocardial infarction. Five of eight sphingolipids partially mediated the association between eGFR and heart failure. The sphingolipids associated with the greatest proportion mediated were ceramide-16:0 (proportion mediated 13%, 95% CI 8-22%) and sphingomyelin-16:0 (proportion mediated 10%, 95% CI 5-17%). No sphingolipids mediated the association between eGFR and ischemic stroke.

INTERPRETATION

Plasma sphingolipids partially mediated the association between lower eGFR and incident heart failure. Altered sphingolipids metabolism may be a novel mechanism for heart failure in patients with CKD.

FUNDING

This study was supported by T32 DK007467 and a KidneyCure Ben J. Lipps Research Fellowship (Dr. Lidgard). Sphingolipid measurements were supported by R01 HL128575 (Dr. Lemaitre) and R01 HL111375 (Dr. Hoofnagle) from the National Heart, Lung, and Blood Institute (NHLBI).

Oral Anticoagulation in Patients With Advanced Chronic Kidney Disease and Atrial Fibrillation: Beyond Anticoagulation

The optimal approach to prevent stroke and systemic embolism in patients with advanced chronic kidney disease (CKD) and atrial fibrillation remains unresolved. We conducted a narrative review to explore areas of uncertainty and opportunities for future research. First, the relationship between atrial fibrillation and stroke is more complex in patients with advanced CKD than in the general population. The currently employed risk stratification tools do not adequately discriminate between patients deriving a net benefit and those suffering a net harm from oral anticoagulation. Anticoagulation initiation should probably be more restrictive than is currently advocated by official guidelines. Recent evidence reveals that the superior benefit-risk profile of non-vitamin K antagonist oral anticoagulants (NOACs) vs vitamin K antagonists (VKAs) observed in the general population and in moderate CKD can be extended to advanced CKD. The NOACs yield better protection against stroke, cause less major bleeding, are associated with less acute kidney injury and a slower decline of CKD, and are associated with a lower incidence of cardiovascular events than VKAs. The VKAs may be harmful in CKD patients, in particular in patients with a high bleeding risk and labile international normalized ratio. The better safety and efficacy of NOACs as opposed to VKAs may be particularly evident in advanced CKD as a result of better on-target anticoagulation with NOACs, harmful off-target vascular effects of VKAs, and beneficial off-target vascular effects of NOACs. The intrinsic vasculoprotective effects of NOACs are supported by animal experimental evidence as well as by findings of large clinical trials and may result in use of NOACs beyond their anticoagulant properties.

Role of Anticoagulants for Stroke Prevention in Low-Risk Population Having Atrial Fibrillation and Chronic Kidney Disease: A Systematic Review

Over the last few years, there has been a rising incidence of atrial fibrillation and chronic kidney disease cases. Stroke is the major complication seen in such patients. The combination of both diseases makes patient management more tedious. PubMed and Google Scholar underwent screening with keywords and a Medical Subject Heading (MeSH) combination. The words were "atrial fibrillation," "chronic kidney disease/chronic renal insufficiency," "anticoagulation," "efficacy," and "left atrial appendage occlusion." Articles had screening and appraisal. With the English language as a filter, papers from 2002 to 2022 are part of this review. We reviewed studies including male patients with atrial fibrillation and chronic kidney disease under 65 years to see their risk-benefit from anticoagulation. In addition, left atrial appendage occlusion (LAAO) is also compared. A total of eight articles are part of this systematic review. Age plays a more prominent role than gender regarding the impact of drugs on stroke prevention. LAAO also shows a better outcome than oral anticoagulation, provided people agree to undergo surgery. More studies must be done for this target population, especially comparing results with LAAO and oral anticoagulation.

Frequency of kidney dysfunction in patients with acute stroke and the relationship with the type, severity and outcome

BACKGROUND/AIM

Kidney dysfunction is an established risk factor for cardiovascular diseases including stroke. The study aimed at assessing the frequency of kidney dysfunction in patients with acute stroke and to evaluate the relationship to the type, severity and outcome of stroke. To establish a relationship, which has not been explained in past studies.

MATERIALS AND METHODS

This was a cross-sectional analytical study on acute stroke patients and matched controls, evaluating for kidney dysfunction using both estimated glomerular filtration rate (GFR) and the spot urine protein creatinine ratio. The type of stroke was observed by neuroimaging. The National Institute of Health Stroke Score was used to assess the severity of stroke at presentation and outcome after 7 days. Data analysis was done using Statistical Package for Social Sciences (SPSS) application version 23.0 (SPSS Inc., Chicago, IL, USA).

RESULTS

: Ninety-eight patients and 100 controls were recruited, with a mean age of 64.7 ± 15.5 and 64.8 ± 15.1 years, respectively. The patients with stroke had a statistically significant higher frequency of kidney dysfunction compared to the controls (85.9% vs. 62.0%, P ≤ 0.001). Patients with haemorrhagic stroke had a higher frequency of kidney dysfunction compared with those with ischaemic stroke (93.8% vs. 77.3%, P = 0.048). The proportion of patients with kidney dysfunction was seen to increase from those with mild to those with severe stroke symptoms, both at presentation and after 7 days. Estimated GFR was seen to be an independent predictor of poor outcome in patients with stroke (odds ratio 0.955, 95% confidence interval 0.924 - 0.986, P = 0.005).

CONCLUSION

The study demonstrated that in patients with acute stroke there is a high frequency of kidney dysfunction. Haemorrhagic stroke, increasing stroke severity and poor outcome were seen to be associated with kidney dysfunction. Thus, recommending the need for kidney care as an important part of stroke management.

Kidney Disease, Hypertension Treatment, and Cerebral Perfusion and Structure

RATIONALE & OBJECTIVE

The safety of intensive blood pressure (BP) targets is controversial for persons with chronic kidney disease (CKD). We studied the effects of hypertension treatment on cerebral perfusion and structure in individuals with and without CKD.

STUDY DESIGN

Neuroimaging substudy of a randomized trial.

SETTING & PARTICIPANTS

A subset of participants in the Systolic Blood Pressure Intervention Trial (SPRINT) who underwent brain magnetic resonance imaging studies. Presence of baseline CKD was assessed by estimated glomerular filtration rate (eGFR) and urinary albumin-creatinine ratio (UACR).

INTERVENTION

Participants were randomly assigned to intensive (systolic BP <120 mm Hg) versus standard (systolic BP <140 mm Hg) BP lowering.

OUTCOMES

The magnetic resonance imaging outcome measures were the 4-year change in global cerebral blood flow (CBF), white matter lesion (WML) volume, and total brain volume (TBV).

RESULTS

A total of 716 randomized participants with a mean age of 68 years were enrolled; follow-up imaging occurred after a median 3.9 years. Among participants with eGFR <60 mL/min/1.73 m2 (n = 234), the effects of intensive versus standard BP treatment on change in global CBF, WMLs, and TBV were 3.38 (95% CI, 0.32 to 6.44) mL/100 g/min, -0.06 (95% CI, -0.16 to 0.04) cm3 (inverse hyperbolic sine-transformed), and -3.8 (95% CI, -8.3 to 0.7) cm3, respectively. Among participants with UACR >30 mg/g (n = 151), the effects of intensive versus standard BP treatment on change in global CBF, WMLs, and TBV were 1.91 (95% CI, -3.01 to 6.82) mL/100 g/min, 0.003 (95% CI, -0.13 to 0.13) cm3 (inverse hyperbolic sine-transformed), and -7.0 (95% CI, -13.3 to -0.3) cm3, respectively. The overall treatment effects on CBF and TBV were not modified by baseline eGFR or UACR; however, the effect on WMLs was attenuated in participants with albuminuria (P = 0.04 for interaction).

LIMITATIONS

Measurement variability due to multisite design.

CONCLUSIONS

Among adults with hypertension who have primarily early kidney disease, intensive versus standard BP treatment did not appear to have a detrimental effect on brain perfusion or structure. The findings support the safety of intensive BP treatment targets on brain health in persons with early kidney disease.

FUNDING

SPRINT was funded by the National Institutes of Health (including the National Heart, Lung, and Blood Institute; the National Institute of Diabetes and Digestive and Kidney Diseases; the National Institute on Aging; and the National Institute of Neurological Disorders and Stroke), and this substudy was funded by the National Institutes of Diabetes and Digestive and Kidney Diseases.

TRIAL REGISTRATION

SPRINT was registered at ClinicalTrials.gov with study number NCT01206062.

Chronic kidney disease and atrial fibrillation: A dangerous combination

Background

Chronic kidney disease (CKD) and atrial fibrillation (AF) are both risk factors for bleeding, stroke and mortality. The aim of our study was to investigate the interaction between CKD and atrial fibrillation and outcomes.

Methods

We included 12,394 subjects referred to the University Medical Center Utrecht (the Netherlands) from September 1996 to February 2018 for an out-patient visit (Utrecht Cardiovascular Cohort Second Manifestation of Arterial disease cohort). Hazard ratios (HRs) with 95% confidence intervals (CIs) for bleeding, ischemic stroke or mortality were calculated with Cox proportional hazard analyses. Presence of interaction between AF and CKD was examined by calculating the relative excess risk due to interaction (RERI), the attributable proportion (AP) due to interaction and the synergy index (S).

Results

Of the 12,394 patients, 699 patients had AF, 2,752 patients had CKD and 325 patients had both AF and CKD. Patients with both CKD and AF had a 3.0-fold (95% CI 2.0–4.4) increased risk for bleeding, a 4.2-fold (95% CI 3.0–6.0) increased ischemic stroke risk and a 2.2-fold (95% CI 1.9–2.6) increased mortality risk after adjustment as compared with subjects without atrial fibrillation and CKD. We did not find interaction between AF and CKD for bleeding and mortality. However, we found interaction between AF and CKD for ischemic stroke risk (RERI 1.88 (95% CI 0.31–3.46), AP 0.45 (95% CI 0.17–0.72) and S 2.40 (95% CI 1.08–5.32)).

Conclusion

AF and CKD are both associated with bleeding, ischemic stroke and mortality. There is a positive interaction between AF and CKD for ischemic stroke risk, but not for bleeding or mortality.

Increased Cerebral Small Vessel Disease Burden With Renal Dysfunction and Albuminuria in Patients Taking Antithrombotic Agents: The Bleeding With Antithrombotic Therapy 2

Background The aim of this study was to determine the associations of cerebral small vessel disease (SVD) burden with renal dysfunction and albuminuria in patients taking oral antithrombotic agents. Methods and Results Patients who newly started or continued taking oral antiplatelets or anticoagulants were enrolled in a prospective, multicenter, observational study. Obligatorily acquired multimodal magnetic resonance imaging at registration with prespecified imaging conditions was assessed for cerebral microbleeds, white matter hyperintensities, enlarged basal ganglia perivascular spaces, or lacunes, and an ordinal SVD score was calculated (range, 0-4). Multivariable adjusting covariates were age, sex, hypertension, diabetes, dyslipidemia, current smoking, drinking, and estimated glomerular filtration rate (eGFR). Of 5324 patients (1762 women; median age, 73 years), 4797 (90.1%) patients were taking oral antithrombotic agents for secondary stroke prevention. Cerebral microbleeds were present in 32.7%, confluent white matter hyperintensities in 51.8%, extensive basal ganglia perivascular spaces in 38.9%, and lacunes in 59.4%. Median SVD score was 2. Compared with eGFR category G1 (eGFR ≥90 mL/min per 1.73 m2), adjusted odds ratios for SVD score increment were 1.63 (95% CI, 1.11-2.39) at category G4 (eGFR 15-<30 mL/min per 1.73 m2) and 2.05 (95% CI, 1.33-3.16) at G5 (eGFR <15 mL/min per 1.73 m2). Corresponding odds ratios relative to urinary albumin-to-creatinine ratio (ACR) category A1 (ACR <30 mg/g) were 1.29 (95% CI, 1.12-1.49) for category A2 (ACR 30-<300 mg/g) and 1.37 (95% CI, 1.05-1.77) for A3 (ACR ≥300 mg/g). When combined eGFR and ACR categories were assessed, risks for SVD score increment generally increased as eGFR decreased and ACR increased. Conclusions Both reduced eGFR and albuminuria were independently associated with increased cerebral SVD burden in patients requiring oral antithrombotic medication mainly for secondary stroke prevention. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01581502; URL: https://www.umin.ac.jp/ctr; Unique identifier: UMIN000023669.

OUP accepted manuscript

Background

Methods

Results

Conclusions

Chronic kidney disease as a risk factor for acute stroke

One of the most relevant issues of nephrology, neurology, and cardiology is the management and treatment of patients with chronic kidney disease and stroke. Patients with chronic kidney disease have a risk of both thrombotic complications and bleeding, and they have a high risk of both ischemic and hemorrhagic stroke. Chronic kidney disease significantly worsens the outcome of stroke by limiting the treatment due to reduced drug clearance and side effects. Hemodialysis which causes drastic hemodynamic and biochemical changes leads to the "stress" of the cerebral vascular system, increasing the risk of stroke; kidney transplantation reduces the risk of stroke due to functional recovery. Chronic kidney disease and stroke have significant socio-economic consequences. Patients with end-stage chronic kidney disease, as a rule, are not included in clinical trials; and stroke treatment tactics have not been developed for them. This review examines the interaction between kidneys and brain, the pathophysiology and epidemiology of stroke in all stages of chronic kidney disease, after kidney transplantation and discusses the management and treatment of chronic kidney disease patients with stroke.

The investigation of the factors responsible for the high prevalence of brain lesions in chronic kidney disease will allow developing new treatment methods.

Medical therapies for prevention of cardiovascular and renal events in patients with atrial fibrillation and diabetes mellitus

Atrial fibrillation (AF), type 2 diabetes mellitus (DM), and chronic kidney disease (CKD) are three global epidemics with significant effects on morbidity and mortality. Diabetes is a risk factor for AF, and a risk factor for thromboembolism, comorbidity, and mortality when AF is present. The pathophysiology of diabetes-related AF and interrelationships with cardiovascular events and renal events is not fully understood but is in part related to structural, electrical, electromechanical, and autonomic remodelling. The current practice guidelines offer limited recommendations on the management of patients with AF (or risk of AF) and diabetes with its own heterogeneity for the prevention of cardiovascular and renal events. This document discusses possible clinical approaches for these patients. In the last decade, there have been major improvements for the prevention of stroke in AF patients with direct oral anticoagulants, which are preferable to vitamin K antagonists for stroke prevention in DM. Because of the increased risk rate for several cardiovascular adverse events in diabetic patients, a similar relative risk reduction generally translates into greater absolute risk reduction in the diabetic population. Recent trials with non-insulin diabetes drugs using glucagon-like peptide-1 agonists and sodium-glucose cotransporter-2 inhibitors showed a significant reduction for the risk of major adverse cardiovascular events in patients with type 2 DM. Sodium-glucose cotransporter-2 inhibitors also showed a large reduction in hospitalization for heart failure and renal events, which need to be more completely evaluated in patients with AF. Mechanisms, risks, and optimal management of AF patients with DM who have or are under risk of developing heart failure or CKD are also discussed in this document. The benefits of medical therapies for these patients still need to be put into perspective, and gaps in evidence on some of these issues are likely to be addressed in future years.

The role of urinary albumin-to-creatinine ratio as a biomarker to predict stroke: A meta-analysis and systemic review

Albuminuria excretion rate, calculated as urinary albumin-to-creatinine ratio (UACR), is used clinically to evaluate albuminuria. There are different attitudes to whether high UACR predicts higher risk of stroke. The aim of this study was to evaluate the relationship between UACR and stroke. Two investigators independently searched MEDLINE, EMBASE, Cochrane Controlled Trials Register Database, Scopus and Google Scholar from January 1966 through June 2021 were screened. In addition, a manual search was conducted using the bibliographies of original papers and review articles on this topic. Two blinded reviewers abstracted the data independently to a predefined form. Among the 10,939 initially identified studies, 7 studies with 159,302 subjects were finally included. It is demonstrated that UACR predicted an increased risk of stroke using cutoff value of either 0.43 (HR, 2.39; 95% CI: 1.24 - 4.61; P <0.01), 10 mg/g (HR, 1.60; 95% CI: 1.30 - 1.97; P < 0.01) or 30 mg/g (HR, 1.84; 95% CI: 1.49 - 2.28; P < 0.01). The overall analysis confirmed that high UACR was associated with an increased rate of stroke (HR, 1.81; 95% CI: 1.52 - 2.17; P < 0.01). Furthermore, High UACR predicted higher risk of stroke in local inhabitants (HR, 1.67; 95% CI: 1.17 – 2.37; P = 0.04), adults (HR, 2.21; 95% CI: 2.07 – 2.36; P < 0.01) or elderly adults (HR, 1.96; 95% CI: 1.56 – 2.46; P < 0.01). Whereas, high UACR was unable to predict stroke in patients with either T2DM (HR, 2.25; 95% CI: 0.55 – 9.17; P = 0.26) or hypertension (HR, 0.95; 95% CI: 0.28 – 3.22; P = 0.93). Another subgroup analysis revealed that high UACR was associated with increased risk of ischemic stroke (HR, 1.60; 95% CI: 1.43 - 1.80; P < 0.01), as well as hemorrhagic stroke (HR, 1.76; 95% CI: 1.22 - 1.45; P < 0.01). In conclusion, UACR is associated with an increased risk of hemorrhagic and ischemic stroke. UACR may be used as an indicator to predict stroke in non-diabetic and non-hypertensive subjects.

Urinary albumin-to-creatinine ratio and the risk of first stroke in Chinese hypertensive patients treated with angiotensin-converting enzyme inhibitors

We aimed to evaluate the relationship of the albumin-to-creatinine ratio (ACR) with the risk of first stroke and examine possible effect modifiers in hypertensive patients. A total of 11,632 hypertensive participants with urinary ACR measurements and without a history of stroke from the China Stroke Primary Prevention Trial (CSPPT) were included in this analysis. The primary outcome was first stroke. Over a median follow-up of 4.4 years, 728 first strokes were identified, of which 633 were ischemic, 89 were hemorrhagic, and 6 were uncertain types. Overall, there was a significant positive association between natural log-transformed ACR and the risk of first stroke (HR, 1.11; 95% CI: 1.03-1.20) and first ischemic stroke (HR, 1.12; 95% CI: 1.03-1.22). Consistently, participants with ACR ≥ 10 mg/g had a significantly higher risk of first stroke (HR, 1.26; 95% CI: 1.06-1.50) and first ischemic stroke (HR, 1.33; 95% CI: 1.10-1.59) than those with ACR < 10 mg/g. Moreover, the association of ACR with first stroke was significantly stronger in participants with higher total homocysteine (tHcy) levels (<10 versus ≥ 10 μmol/L; P for interaction = 0.044). However, there was no significant association between ACR and first hemorrhagic stroke (per natural log [ACR] increment: HR, 1.02; 95% CI: 0.82-1.27). In summary, hypertensive patients with ACR ≥ 10 mg/g had a significantly increased risk of first stroke or first ischemic stroke. This positive association was more pronounced among participants with higher tHcy levels.

Adverse outcomes after partner bereavement in people with reduced kidney function: Parallel cohort studies in England and Denmark

OBJECTIVES

To investigate whether partner bereavement is associated with adverse cardiovascular and kidney-related events in people with reduced kidney function.

DESIGN

Two parallel matched cohort studies using linked routinely collected health data.

SETTING

England (general practices and hospitals using linked Clinical Practice Research Datalink, Hospital Episode Statistics, and Office of National Statistics) and Denmark (hospitals and community pharmacies using the Danish National Patient, Prescription and Education Registries and the Civil Registration System).

PARTICIPANTS

Bereaved people with reduced kidney function (estimated glomerular filtration rate (eGFR) <60mL/min/1.73m2 (England) or hospital-coded chronic kidney disease (Denmark)) and non-bereaved people with reduced kidney function similarly defined, matched on age, sex, general practice (England), and county of residence (Denmark) and followed-up from the bereavement date of the exposed person.

MAIN OUTCOME MEASURES

Cardiovascular disease (CVD) or acute kidney injury (AKI) hospitalization, or death.

RESULTS

In people with reduced kidney function, we identified 19,820 (England) and 5,408 (Denmark) bereaved individuals and matched them with 134,828 (England) and 35,741 (Denmark) non-bereaved individuals. Among the bereaved, the rates of hospitalizations (per 1000 person-years) with CVD were 31.7 (95%-CI: 30.5-32.9) in England and 78.8 (95%-CI: 74.9-82.9) in Denmark; the rates of hospitalizations with AKI were 13.2 (95%-CI: 12.5-14.0) in England and 11.2 (95%-CI: 9.9-12.7) in Denmark; and the rates of death were 70.2 (95%-CI: 68.5-72.0) in England and 126.4 (95%-CI: 121.8-131.1) in Denmark. After adjusting for confounders, we found increased rates of CVD (England, HR 1.06 [95%-CI: 1.01-1.12]; Denmark, HR 1.10 [95%-CI: 1.04-1.17]), of AKI (England, HR 1.20 [95%-CI: 1.10-1.31]; Denmark HR 1.36 [95%-CI: 1.17-1.58]), and of death (England, HR 1.10 [95%-CI: 1.05-1.14]; Denmark HR 1.20 [95%-CI: 1.15-1.25]) in bereaved compared with non-bereaved people.

CONCLUSIONS

Partner bereavement is associated with an increased rate of CVD and AKI hospitalization, and death in people with reduced kidney function. Additional supportive care for this at-risk population may help prevent serious adverse events.

An association between electronic nicotine delivery systems use and a history of stroke using the 2016 behavioral risk factor surveillance system

ABSTRACT

Electronic nicotine delivery systems (ENDS) are growing in use and many of the health implications with these devices remain unknown. This study aims to assess, using a survey representative of the USA general population, if an association exists between a history of ENDS use and a history of stroke.This cross-sectional study was a secondary data analysis using the 2016 behavioral risk factor surveillance system survey. The main exposure variable of the study was a self-reported history of ENDS use. The main outcome was a self-reported history of stroke. Covariates included sex, race, traditional cigarette use, smokeless tobacco use, chronic kidney disease, diabetes, myocardial infarction, and coronary artery disease. Unadjusted and adjusted logistic regression analyses were done. Adjusted odds ratios (AOR) and their corresponding 95% confidence intervals (CI) were calculated.Of the 486,303 total behavioral risk factor surveillance system survey participants, 465,594 met the inclusion criteria for this study of ENDS use and stroke. This study shows that current ENDS use was positively associated with a history of stroke. AOR of some daily ENDS use with stroke was 1.28 (95% CI: 1.02-1.61) and AOR of current daily ENDS use with stroke was 1.62 (95% CI: 1.18-2.31). The majority (55.9%) of current daily ENDS users reported former traditional cigarette smoking. Female sex, non-white ethnicity, elderly age, chronic kidney disease, coronary artery disease, diabetes, and traditional cigarette use characteristics were all also associated with increased odds of reporting a stroke.This study found a statistically significant and positive association between ENDS use and a history of stroke. Further research is warranted to investigate the reproducibility and temporality of this association. Nevertheless, this study contributes to the growing body of knowledge about the potential cardiovascular concerns related to ENDS use and the need for large cohort studies.

Effect of SGLT2 Inhibitors on Stroke and Atrial Fibrillation in Diabetic Kidney Disease: Results From the CREDENCE Trial and Meta-Analysis

BACKGROUND AND PURPOSE

Chronic kidney disease with reduced estimated glomerular filtration rate or elevated albuminuria increases risk for ischemic and hemorrhagic stroke. This study assessed the effects of sodium glucose cotransporter 2 inhibitors (SGLT2i) on stroke and atrial fibrillation/flutter (AF/AFL) from CREDENCE (Canagliflozin and Renal Events in Diabetes With Established Nephropathy Clinical Evaluation) and a meta-analysis of large cardiovascular outcome trials (CVOTs) of SGLT2i in type 2 diabetes mellitus.

METHODS

CREDENCE randomized 4401 participants with type 2 diabetes mellitus and chronic kidney disease to canagliflozin or placebo. Post hoc, we estimated effects on fatal or nonfatal stroke, stroke subtypes, and intermediate markers of stroke risk including AF/AFL. Stroke and AF/AFL data from 3 other completed large CVOTs and CREDENCE were pooled using random-effects meta-analysis.

RESULTS

In CREDENCE, 142 participants experienced a stroke during follow-up (10.9/1000 patient-years with canagliflozin, 14.2/1000 patient-years with placebo; hazard ratio [HR], 0.77 [95% CI, 0.55-1.08]). Effects by stroke subtypes were: ischemic (HR, 0.88 [95% CI, 0.61-1.28]; n=111), hemorrhagic (HR, 0.50 [95% CI, 0.19-1.32]; n=18), and undetermined (HR, 0.54 [95% CI, 0.20-1.46]; n=17). There was no clear effect on AF/AFL (HR, 0.76 [95% CI, 0.53-1.10]; n=115). The overall effects in the 4 CVOTs combined were: total stroke (HR_pooled, 0.96 [95% CI, 0.82-1.12]), ischemic stroke (HR_pooled, 1.01 [95% CI, 0.89-1.14]), hemorrhagic stroke (HR_pooled, 0.50 [95% CI, 0.30-0.83]), undetermined stroke (HR_pooled, 0.86 [95% CI, 0.49-1.51]), and AF/AFL (HR_pooled, 0.81 [95% CI, 0.71-0.93]). There was evidence that SGLT2i effects on total stroke varied by baseline estimated glomerular filtration rate (P=0.01), with protection in the lowest estimated glomerular filtration rate (<45 mL/min/1.73 m²]) subgroup (HR_pooled, 0.50 [95% CI, 0.31-0.79]).

CONCLUSIONS

Although we found no clear effect of SGLT2i on total stroke in CREDENCE or across trials combined, there was some evidence of benefit in preventing hemorrhagic stroke and AF/AFL, as well as total stroke for those with lowest estimated glomerular filtration rate. Future research should focus on confirming these data and exploring potential mechanisms. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02065791.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Cystatin C is a potential predictor of unfavorable outcomes for cerebral ischemia with intravenous tissue plasminogen activator treatment: A multicenter prospective nested case-control study

BACKGROUND AND PURPOSE

The aim of this study was to explore whether cystatin C (CysC) could be used as a potential predictor of clinical outcomes in acute ischemic stroke (AIS) patients treated with intravenous tissue plasminogen activator (IV-tPA).

METHODS

We performed an observational study including a retrospective analysis of data from 125 AIS patients with intravenous thrombolysis. General linear models were applied to compare CysC levels between groups with different outcomes; logistic regression analysis and receiver-operating characteristic curves were adopted to identify the association between CysC and the therapeutic effects.

RESULTS

Compared with the "good and sustained benefit" (GSB) outcome group (defined as ≥4-point reduction in National Institutes of Health Stroke Scale or a score of 0-1 at 24 h and 7 days) and the "good functional outcome" (GFO) group (modified Rankin Scale score 0-2 at 90 days), serum CysC baseline levels were increased in the non-GSB and non-GFO groups. Logistic regression analysis found that CysC was an independent negative prognostic factor for GSB (odds ratio [OR] 0.010; p = 0.005) and GFO (OR 0.011; p = 0.021) after adjustment for potential influencing factors. Receiver-operating characteristic curves showed the CysC-involved combined models provided credible efficacy for predicting post-90-day favorable clinical outcome (area under the curve 0.86; p < 0.001).

CONCLUSIONS

Elevated serum CysC is independently associated with unfavorable clinical outcomes after IV-tPA therapy in AIS. Our findings provide new insights into discovering potential mediators for neuropathological process or treatment in stroke.

Reduced Glomerular Filtration Rate and Risk of Stroke: A Nationwide Cohort Study in South Korea

Aims: Although chronic kidney disease is recognized as an independent risk factor for cerebrovascular disease, its association with hemorrhagic and ischemic stroke remains controversial.

Methods: We conducted a retrospective cohort study using the National Health Insurance Service-National Sample Cohort, which is representative of the Korean population. A total of 195,772 Koreans who were not diagnosed with stroke before 2009 were included in this study from 2009 to 2013. The eGFR was divided into six categories (≥ 90, 75–89, 60–74, 45–59, 30–44, ＜30 mL/min/1.73 m ² ). The Kaplan–Meier plot was illustrated to compare the incidence of stroke. Cox proportional hazard model was used to estimate the hazard ratio (HR) of eGFR for risk of ischemic and hemorrhagic stroke by sex.

Results: During an average of 4.36 years of follow-up period, 2,236 and 668 people were diagnosed with newly ischemic and hemorrhagic stroke, respectively. Age-adjusted incidence rate for ischemic stroke among people with eGFR ＜45 mL/min/1.73 m ² was higher than those with eGFR ≥ 90 mL/min/1.73 m ² , whereas that for hemorrhagic stroke among people with eGFR ≥ 90 mL/min/1.73 m ² was higher than those with eGFR ＜45 mL/min/1.73 m ² . After adjusting for multiple covariates, the adjusted HR for ischemic stroke increased with decreasing eGFR in men ( p for trend ＜0.001), but not in women ( p for trend=0.48). On the other hand, there was no significant relationship between eGFR and risk of hemorrhagic stroke in both men and women.

Conclusions: Reduced glomerular filtration rate less than 45 mL/min/1.73 m ² was associated with an increased risk of ischemic stroke, especially in men.

Association of lipid profiles with severity and outcome of acute ischemic stroke in patients with and without chronic kidney disease

Background

Contribution of lipid profiles to stroke severity and outcome was inconclusive, whether chronic kidney disease (CKD) (estimated glomerular filtration rate < 60 mL/min/1.73 m²) affects the association has not been investigated. We aim to evaluate this relationship.

Methods

A retrospective study of consecutive acute ischemic stroke patients was performed. We assessed the risk of severe stroke with the National Institutes of Health Stroke Scale (NIHSS) ≥ 5 at admission and poor outcome with the modified Rankin Scale (mRS) ≥ 3 at discharge. Multivariate stepwise logistic regression models were adopted to study interaction and independent association of lipid components with stroke severity and outcome according to lipid level quartiles by CKD stratification.

Results

Among the 875 included patients (mean age 64.9 years, 67.8% males), 213 (24.3%) presented with CKD. Elevated low-density lipoprotein cholesterol (LDL-C) was independently associated with severe stroke in patients with CKD (P for trend = 0.033) than in those without CKD (P for trend = 0.121). The association between the level of LDL-C and stroke severity was appreciably modified by CKD (P_interaction = 0.013). Compared with without CKD patients in the lowest LDL-C quartile, the multivariable-adjusted risk of severe stroke increased significantly by 2.9-fold (95% CI 1.48–5.74) in patients with CKD in the highest LDL-C quartile. No significant association was observed between lipid components and early outcome in patients with and without CKD.

Conclusion

LDL-C levels are positively associated with stroke severity in only patients with CKD, with an interactive impact of LDL-C and CKD on ischemic stroke in the acute phase.

Decline in kidney function over the course of adulthood and cognitive function in midlife

OBJECTIVE

To test the hypothesis that end-stage renal disease (ESRD) risk exposure during young adulthood is related to worse cognitive performance in midlife.

METHODS

We included 2,604 participants from the population-based Coronary Artery Risk Development in Young Adults (CARDIA) Study (mean age 35 years, 54% women, 45% Black). Estimated glomerular filtration rate and albumin-to-creatinine ratio were measured every 5 years at year (Y) 10 through Y30. At each visit, moderate/high risk of ESRD according to the Kidney Disease: Improving Global Outcomes guidelines (estimated glomerular filtration rate <60 mL/min/1.73 m² or albumin-to-creatinine ratio >30 mg/g) was defined, totaled over examinations, and categorized into 0 episodes, 1 episode, and >1 episodes of ESRD risk. At Y30, participants underwent global and multidomain cognitive assessment. We used analysis of covariance to assess the association of ESRD risk categories with cognitive function, controlling for cardiovascular risk factors.

RESULTS

Over the course of 20 years, 427 participants (16% of the study population) had ≥1 episodes of ESRD risk exposure. Individuals with more risk episodes had lower composite cognitive function (p < 0.001), psychomotor speed (p < 0.001), and executive function (p = 0.007). All these associations were independent of sociodemographic status and cardiovascular risk factors.

CONCLUSIONS

In this population-based longitudinal study, we show that episodes of decline in kidney function over the young-adulthood course are associated with worse cognitive performance at midlife. Preserving kidney function in young age needs to be investigated as a potential strategy to preserve cognitive function in midlife.

Association between kidney disease measures and intracranial atherosclerosis: The ARIC study

OBJECTIVE

To test the association between reduced kidney function (assessed by estimated glomerular filtration rate [eGFR] and cystatin C [CysC]) and kidney damage (assessed by urinary albumin-to-creatinine ratio [ACR]) and intracranial atherosclerotic disease (ICAD) by high-resolution vessel wall MRI (VWMRI) in the Atherosclerosis Risk in Communities Neurocognitive Study (ARIC-NCS).

METHODS

We conducted a cross-sectional analysis of ARIC participants with data on kidney measures and VWMRI in 2011 to 2013. The main outcomes were presence of intracranial plaques and luminal stenosis. Multivariable models were adjusted for demographics, cardiovascular risk factors, and use of antithrombotic medications.

RESULTS

A total of 1,762 participants (mean ± SD age, 76.3 ± 5.3) were included. eGFR based on CysC (eGFRcysc) <60 mL/min/1.73 m2 (vs ≥60 mL/min/1.73 m2) was associated with plaque presence (adjusted odds ratio [OR] 1.29, 95% confidence interval [CI] 1.04-1.60), any detectable stenosis (adjusted OR 1.31, 95% CI 1.04-1.63), and >70% stenosis or occlusion (adjusted OR 2.15, 95% CI 1.32-3.50). Neither ACR nor CysC showed statistically significant associations with ICAD features in adjusted models. In adjusted multinomial models, participants with eGFRcysc <60 mL/min/1.73 m2 (vs ≥60 mL/min/1.73 m2) had an increased OR of 1.41 (95% CI 1.06-1.87) for having 1 plaque (vs none) but no significant increase for multiple plaques; ACR ≥30 was associated with moderate (50%-70%) stenosis (OR 2.01, 95% CI 1.14-3.55) vs absent or less than 50% stenosis.

CONCLUSION

In community-dwelling older adults, reduced kidney function or elevated kidney damage was associated with ICAD measured by VWMRI. This finding may help to better identify a population at high risk for ICAD.

Urinary dysfunction in acute brain injury: A narrative review

The frontal lobe urinary control center is an important regulator of urinary function. Neurologic injury often causes damage or temporary dysfunction of this center and other related urinary control pathways. Little has been reported about this topic in the literature although a majority of neurologic injury patients suffer from some type of urinary dysfunction. In this review, we highlight what is known about urinary dysfunction based on injury type (traumatic brain injury, hemorrhagic stroke, ischemic stroke, subarachnoid hemorrhage, subdural hematoma, and epilepsy). We discuss both clinical and pre-clinical data and pinpoint areas warranting further investigation. In the final section, we provide proposed practice suggestions for managing these patients clinically with the intended goal for refinement in these approaches following further clinical trials.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Correlation Between Neutrophil Count and Prognosis in STEMI Patients with Chronic Renal Dysfunction: A Retrospective Cohort Study

Neutrophil is a key element in inflammation and stress disease, which are associated with poor clinical outcomes in various cardiac diseases. However, the clinical availability of neutrophil in patients with ST-elevation myocardial infarction (STEMI) and chronic renal dysfunction has not been known. Accordingly, we designed this retrospective cohort study to evaluate the differences of major adverse cardiovascular events incidence between renal dysfunctional STEMI patients with normal and high neutrophil levels. The primary end point was all-cause mortality. We analyzed 377 consecutive STEMI patients with chronic renal dysfunction. The results showed that during 12-48 months follow-up, death from any-cause occurred in 1.4% patients (4 of 290) in normal-level neutrophil group, as compared with 3.4% in high-level neutrophil group (3 of 87) (hazard ratio, 2.174 95% confidence interval, 1.024-10.248; P = 0.025). Kaplan-Meier survival analysis showed that there were significant differences between the two groups with respect to the risk of death (P=0.018), and heart failure (P=0.037).

Is there a cardiovascular protective effect of aspirin in chronic kidney disease patients? A systematic review and meta-analysis

PURPOSE

To perform a systematic review and meta-analysis to evaluate the cardiovascular prevention effect of aspirin among patients with chronic kidney disease (CKD).

METHODS

A comprehensive literature search was conducted in Embase, PubMed, and Cochrane library (up to March 2019) without language limitations. Randomized control trials (RCT) and observational studies that met the inclusion and exclusion criteria were included. Two reviewers independently extracted data, and evaluated study quality using modified Jadad score for RCTs and Newcastle-Ottawa Scale for observational study. A meta-analysis was conducted in the Stata 15.0 software using the DerSimonian and Laird random-effects model.

RESULTS

1768 references were identified from literature searching. Four RCTs and four cohort studies that reported the cardiovascular prevention outcome of aspirin in CKD patients (38,341 participants) were included in this review. The pooled data revealed that aspirin had no significant prevention effect on cardiovascular events among CKD patients (RR = 0.96, 95% CI, 0.59-1.13). There was also no significant reduction in cardiovascular mortality and all-cause mortality. Although we found no significant increased risk in major bleeding events, there was a statistically significant increased risk of minor bleeding events (RR = 2.57, 95% CI, 1.60-4.13) and renal events (RR = 1.30, 95% CI, 1.02-1.65) for aspirin use.

CONCLUSION

Our review indicated that aspirin use in CKD patients had no prevention effect on cardiovascular events and no statistically significant reduction in risk of cardiovascular or all-cause mortality, with a significant increased risk of minor bleeding and renal events.

The Risk of Stroke and Stroke Type in Patients With Atrial Fibrillation and Chronic Kidney Disease

Background:

Atrial fibrillation (AF) and chronic kidney disease (CKD) are known to increase the risk of stroke.

Objectives:

We set out to examine the risk of stroke by kidney function and albuminuria in patients with and without AF.

Design:

Retrospective cohort study.

Settings:

Ontario, Canada.

Participants:

A total of 736 666 individuals (>40 years) from 2002 to 2015.

Measurements:

New-onset AF, albumin-to-creatinine ratio (ACR), and an estimated glomerular filtration rate (eGFR).

Methods:

A total of 39 120 matched patients were examined for the risk of ischemic, hemorrhagic, or any stroke event, accounting for the competing risk of all-cause mortality. Interaction terms for combinations of ACR/eGFR and the outcome of stroke with and without AF were examined.

Results:

In a total of 4086 (5.2%) strokes (86% ischemic), the presence of AF was associated with a 2-fold higher risk for any stroke event and its subtypes of ischemic and hemorrhagic stroke. Across eGFR levels, the risk of stroke was 2-fold higher with the presence of AF except for low levels of eGFR (eGFR < 30 mL/min/1.73 m², hazard ratio [HR]: 1.38, 95% confidence interval [CI]: 0.99-1.92). Similarly across ACR levels, the risk of stroke was 2-fold higher except for high levels of albuminuria (ACR > 30 mg/g, HR: 1.61, 95% CI: 1.31-1.99). The adjusted risk of stroke with AF differed by combinations of ACR and eGFR categories (interaction P value = .04) compared with those without AF. Both stroke types were more common in patients with AF, and ischemic stroke rates differed significantly by eGFR and ACR categories.

Limitations:

Medication information was not included.

Conclusions:

Patients with CKD and AF are at a high risk of total, ischemic, and hemorrhagic strokes; the risk is highest with lower eGFR and higher ACR and differs based on eGFR and the degree of ACR.

Intensive Blood Pressure Treatment Reduced Stroke Risk in Patients With Albuminuria in the SPRINT Trial

Background and Purpose- Albuminuria is associated with stroke risk among individuals with diabetes. However, the association of albuminuria with incident stroke among nondiabetic patients is less clear. Methods- We performed a post hoc analysis of the SPRINT (Systolic Blood Pressure Intervention Trial), which examined the effect of higher versus lower intensity blood pressure management on mortality in 8913 participants without diabetes. We fit unadjusted and adjusted Cox proportional hazards models to estimate the association of baseline albuminuria (urinary albumin-to-creatinine ratio ≥30 mg/g versus<30 mg/g) with stroke risk. We also assessed effect modification according to treatment arms. Results- Mean age was 68±9 years, 35% were female, and 30% were black. Median follow-up was 3.2 years, and 19% patients had baseline albuminuria. Incident stroke occurred in 129 individuals during follow-up. Albuminuria was associated with increased stroke risk (unadjusted hazard ratio, 2.24; 95% CI, 1.55-3.23; adjusted hazard ratio 1.73; 95% CI, 1.17-2.56). The association of albuminuria with incident stroke differed according to the randomized treatment arm (P interaction=0.03). In the intensive treatment arm, the association of albuminuria and stroke was nonsignificant (unadjusted hazard ratio, 1.25; 95% CI, 0.69-2.28), whereas, in the standard treatment arm, it was significant (unadjusted hazard ratio, 3.44; 95% CI, 2.11-5.61). Conclusions- In a post hoc analysis of SPRINT, baseline albuminuria (versus not) was associated with a higher risk of incident stroke, but this relationship appeared to be restricted to those in the standard treatment arm. Further studies are required to conclusively determine if reduction of albuminuria in itself is beneficial in reducing stroke risk. Clinical Trial Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT01206062.

Chronic kidney disease in the pathogenesis of acute ischemic stroke

Chronic kidney disease has a graded and independent inverse impact on cerebrovascular health. Both thrombotic and hemorrhagic complications are highly prevalent in chronic kidney disease patients. Growing evidence suggests that in chronic kidney disease patients, ischemic strokes are more common than hemorrhagic strokes. Chronic kidney disease is asymptomatic until an advanced stage, but mild to moderate chronic kidney disease incites various pathogenic mechanisms such as inflammation, oxidative stress, neurohormonal imbalance, formation of uremic toxins and vascular calcification which damage the endothelium and blood vessels. Cognitive dysfunction, dementia, transient infarcts, and white matter lesions are widespread in mild to moderate chronic kidney disease patients. Uremic toxins produced after chronic kidney disease can pass through the blood-brain barrier and mediate cognitive dysfunction and neurodegeneration. Furthermore, chronic kidney disease precipitates vascular risk factors that can lead to atherosclerosis, hypertension, atrial fibrillation, and diabetes. Chronic kidney disease also exacerbates stroke pathogenesis, worsens recovery outcomes, and limits the eligibility of stroke patients to receive available stroke therapeutics. This review highlights the mechanisms involved in the advancement of chronic kidney disease and its possible association with stroke.

Association of renal function with ambulation in mild acute stroke patients

Background: Renal dysfunction has affected the functional outcome after stroke. However, the association of renal function with walking endurance after stroke is poorly understood. Objectives: This study aimed to investigate the relationship between renal function and walking endurance and speed in mild acute stroke patients. Methods: Eighty-nine patients with mild acute stroke were enrolled. Walking endurance and speed were assessed by the 6-minute walk test (6MWT) and comfortable and maximal 10-meter walk tests (10MWT) within 7 days of hospital admission. Stroke severity was assessed using the National Institutes of Health stroke scale (NIHSS) on admission. The estimated glomerular filtration rate (eGFR) was calculated based on creatinine levels as a renal function. Pearson's correlation coefficients were calculated between eGFR and walking ability. Multivariate regression analysis was used to investigate the relationship between eGFR and walking ability in mild acute stroke patients. Results: The 6MWT distance was significantly correlated with eGFR (r = 0.212, p = .046). On multivariate regression analysis, the 6MWT was significantly associated with age (p = .029), body mass index (p = .020), NIHSS score (p = .016), and eGFR (p = .028), whereas the comfortable 10MWT was significantly associated with the NIHSS score alone (p = .009) and the maximal 10MWT was significantly associated with age (p = .032) and NIHSS score (p = .007). Conclusion: The eGFR based on creatinine levels of acute stroke patients may be important factor to predict the walking endurance in mild acute stroke patients.

The AGES-Reykjavik Study suggests that change in kidney measures is associated with subclinical brain pathology in older community-dwelling persons

Decreased glomerular filtration rate (GFR) and albuminuria may be accompanied by brain pathology. Here we investigated whether changes in these kidney measures are linked to development of new MRI-detected infarcts and microbleeds, and progression of white matter hyperintensity volume. The study included 2671 participants from the population-based AGES-Reykjavik Study (mean age 75, 58.7% women). GFR was estimated from serum creatinine, and albuminuria was assessed by urinary albumin-to-creatinine ratio. Brain MRI was acquired at baseline (2002-2006) and 5 years later (2007-2011). New MRI-detected infarcts and microbleeds were counted on the follow-up scans. White matter hyperintensity progression was estimated as percent change in white matter hyperintensity volumes between the two exams. Participants with a large eGFR decline (over 3 ml/min/1.73m2 per year) had more incident subcortical infarcts (odds ratio 1.53; 95% confidence interval 1.05, 2.22), and more marked progression of white matter hyperintensity volume (difference: 8%; 95% confidence interval: 4%, 12%), compared to participants without a large decline. Participants with incident albuminuria (over 30 mg/g) had 21% more white matter hyperintensity volume progression (95% confidence interval: 14%, 29%) and 1.86 higher odds of developing new deep microbleeds (95% confidence interval 1.16, 2.98), compared to participants without incident albuminuria. The findings were independent of cardiovascular risk factors. Changes in kidney measures were not associated with occurrence of cortical infarcts. Thus, larger changes in eGFR and albuminuria are associated with increased risk for developing manifestations of cerebral small vessel disease. Individuals with larger changes in these kidney measures should be considered as a high risk population for accelerated brain pathology.

Chronic kidney disease and cause-specific hospitalisation: a matched cohort study using primary and secondary care patient data

BACKGROUND

Although chronic kidney disease (CKD) is associated with various outcomes, the burden of each condition for hospital admission is unknown.

AIM

To quantify the association between CKD and cause-specific hospitalisation.

DESIGN AND SETTING

A matched cohort study in primary care using Clinical Practice Research Datalink linked to Hospital Episode Statistics in England.

METHOD

Patients with CKD (estimated glomerular filtration rate <60 mL/min/1.73 m2 for ≥3 months) and a comparison group of patients without known CKD (matched for age, sex, GP, and calendar time) were identified, 2004-2014. Outcomes were hospitalisations with 10 common conditions as the primary admission diagnosis: heart failure; urinary tract infection; pneumonia; acute kidney injury (AKI); myocardial infarction; cerebral infarction; gastrointestinal bleeding; hip fracture; venous thromboembolism; and intracranial bleeding. A difference in the incidence rate of first hospitalisation for each condition was estimated between matched patients with and without CKD. Multivariable Cox regression was used to estimate a relative risk for each outcome.

RESULTS

In a cohort of 242 349 pairs of patients, with and without CKD, the rate difference was largest for heart failure at 6.6/1000 person-years (9.7/1000 versus 3.1/1000 person-years in patients with and without CKD, respectively), followed by urinary tract infection at 5.2, pneumonia at 4.4, and AKI at 4.1/1000 person-years. The relative risk was highest for AKI with a fully adjusted hazard ratio of 4.90, 95% confidence interval (CI) = 4.47 to 5.38, followed by heart failure with 1.66, 95% CI = 1.59 to 1.75.

CONCLUSION

Hospitalisations for heart failure, infection, and AKI showed strong associations with CKD in absolute and(or) relative terms, suggesting targets for improved preventive care.

Proteinuria and risk of stroke in patients with hypertension: The Kailuan cohort study

Proteinuria is associated with stroke, but the effects of changes in proteinuria on stroke risk are not well understood in the hypertensive population. This study examined whether proteinuria changes across 2-year assessments were associated with incident stroke in individuals with hypertension. We used visit data from 24 300 participants with hypertension of the Kailuan study who were stroke free at baseline. Based on the baseline and 2-year dipstick screening results, participants were classified as having no, remittent, incident, or persistent proteinuria. The relationship between proteinuria and stroke was analyzed using Cox proportional-hazards models after adjusting for potential variables. During a median of 6.89-year follow-up, we identified 1197 people with stroke. Compared to those with no proteinuria, stroke risk was significantly increased in participants with incident (hazard ratio [HR] 1.41, 95% CI, 1.05-1.77) and persistent proteinuria (HR 1.49, 95% CI, 1.25-1.89) after adjustment for other factors, which was consistent in ischemic stroke and intracerebral hemorrhage. No interaction was found between changes of proteinuria and diabetes mellitus in the hypertensive population. Changes in proteinuria exposure, particularly persistent proteinuria, play a role in reflecting the risk of stroke in patients with hypertension.

Chronic kidney disease and bleeding risk in patients at high cardiovascular risk: a cohort study

Essentials The association between chronic kidney disease and bleeding is unknown. We followed 10 347 subjects at high cardiovascular risk for bleeding events. Chronic kidney disease was associated with a 1.5-fold increased bleeding risk. Especially albuminuria rather than decreased kidney function was associated with bleeding events.

SUMMARY

Background There are indications that patients with chronic kidney disease have an increased bleeding risk. Objectives To investigate the association between chronic kidney disease and bleeding in patients at high cardiovascular risk. Methods We included 10 347 subjects referred to the University Medical Center Utrecht (the Netherlands) from September 1996 to February 2015 for an outpatient visit with classic risk factors for arterial disease or with symptomatic arterial disease (Second Manifestation of Arterial disease [SMART] cohort). Patients were staged according to the KDIGO guidelines, on the basis of estimated glomerular filtration rate (eGFR) and albuminuria, and were followed for the occurrence of major hemorrhagic events until March 2015. Hazard ratios (HRs) with 95% confidence intervals (CIs) for bleeding were calculated with Cox proportional hazards analyses. Results The incidence rate for bleeding in subjects with chronic kidney disease was 8.0 per 1000 person-years and that for subjects without chronic kidney disease was 3.5 per 1000 person-years. Patients with chronic kidney disease (n = 2443) had a 1.5-fold (95% CI 1.2-1.9) increased risk of bleeding as compared with subjects without chronic kidney disease (n = 7904) after adjustment. Subjects with an eGFR of < 45 mL min-1  1.73 m-2 with albuminuria had a 3.5-fold (95% CI 2.3-5.3) increased bleeding risk, whereas an eGFR of < 45 mL min-1  1.73 m-2 without albuminuria was not associated with an increased bleeding risk (HR 1.3, 95% CI 0.7-2.5). Conclusion Chronic kidney disease is a risk factor for bleeding in patients with classic risk factors for arterial disease or with symptomatic arterial disease, especially in the presence of albuminuria.

Estimated Glomerular Filtration Rate, Proteinuria, and Risk of Cardiovascular Diseases and All-cause Mortality in Diabetic Population: a Community-based Cohort Study

Data about associations between estimated glomerular filtration rate (eGFR) and proteinuria with cardiovascular diseases (CVDs) and all-cause mortality among diabetic population is less described. We aimed to describe these associations in Chinese diabetic population, and investigate the difference between sexes. The study was based on 8,301 diabetic participants in the Kailuan study, who was free of CVDs at baseline. We used Cox proportional hazard models to examine the associations of eGFR and proteinuria with CVDs and all-cause mortality. A stratified analysis by gender was performed. During a median follow-up of 8.05 years, 917 deaths and 813 incident CVDs occurred. Adjusted for all potential confounders, eGFR was associated with all-cause mortality, but not associated with incidence of CVDs. Compared to those with eGFR ≥ 90 ml/min/1.73 m², Participants with eGFR <45 ml/min/1.73 m² had 1.50 fold higher risk of all-cause mortality. Adjusted for all potential confounders, proteinuria was associated with risk of both CVDs and all-cause mortality. Additionally, the risk of all-cause mortality by proteinuria was greater in women than that in men. Both lower eGFR and proteinuria are independent risk factors for all-cause mortality in the Chinese diabetic population. Proteinuria conferred excessive risk for CVDs, and especially in women.

Influence of renal function on the association between homocysteine level and risk of ischemic stroke

We examined whether the association between total homocysteine (tHCY) and risk of ischemic stroke (IS) varies depending on renal function to gain insight into why tHCY-lowering vitamins do not reduce the incidence of cardiovascular disease in clinical trials. We analyzed data from 542 IS patients with large artery atherosclerosis (LAA) or small artery occlusion (SAO) after stratification by estimated glomerular filtration rate (eGFR) to evaluate renal function. We found that tHCY level was positively associated with the occurrence of IS in both LAA (OR: 1.159, 95% CI: 1.074-1.252, P<0.001) and SAO (OR: 1.143, 95% CI: 1.064-1.228, P<0.001) patients and in LAA (OR: 1.135, 95% CI: 1.047-1.230, P=0.002) and SAO (OR: 1.159, 95% CI: 1.060-1.268, P=0.001) subgroups with normal renal function but not in LAA or SAO subgroups with renal insufficiency. eGFR level was positively associated with IS in LAA (OR: 1.022, 95% CI: 1.010-1.034, P<0.001) and SAO (OR: 1.024, 1.012-1.037, P<0.001) subgroups with normal renal function but was negatively associated with IS in LAA (OR: 0.875, 95% CI: 0.829-0.925, P<0.001) and SAO (OR: 0.890, 95% CI: 0.850-0.932, P<0.001) subgroups with renal insufficiency. Folic acid level was negatively associated with IS in LAA (OR: 0.734, 95% CI: 0.606-0.889, P=0.002) and SAO (OR: 0.861, 95% CI: 0.767-0.967, P=0.012) subgroups with renal insufficiency. Therefore, renal function as evaluated by eGFR exerts a significant influence on the association between tHCY and risk of IS.

Serum cystatin C is associated with large cerebral artery stenosis in acute ischemic stroke

Large cerebral artery stenosis is a major cause of acute ischemic stroke (AIS); however, the correlation between serum cystatin C (CysC) and the stenosis of large cerebral arteries in patients with AIS has not been established. We performed a retrospective review of acute ischemic stroke patients, who were examined by cerebral digital subtraction angiography(DSA). Participants (252 cases) included 131 patients without stenosis and 121 patients with large cerebral artery stenosis. Serum CysC levels in patients with large cerebral artery stenosis were much higher than that of control subjects (p<0.001). However, serum CysC levels were not related to the location of stenosis. Further, logistic regression analyses showed that increased serum CysC was an independent risk factor of large cerebral artery stenosis in patients with acute ischemic stroke. Total participants were subdivided into quintiles based on serum CysC levels. Compared with the first quintile, the odds ratios of risk for large cerebral artery stenosis in the fourth and the fifth quintile were 1.26 (p<0.05) and 4.71(p<0.05) respectively, after the adjustment for age, sex, and smoking, hypertension, type 2 diabetes mellitus(DM), dyslipidemia, creatinine(Cr), urea, uric acid, and C reactive protein(CRP). Therefore, a significant positive correlation was observed between elevated serum CysC levels and large cerebral artery stenosis in patients with acute ischemic stroke. In summary, our findings provide new insights into the correlation between increased serum CysC and large cerebral artery stenosis in patients with acute ischemic stroke.

Chronic Kidney Disease and Risk for Gastrointestinal Bleeding in the Community: The Atherosclerosis Risk in Communities (ARIC) Study

BACKGROUND AND OBJECTIVES

Patients on dialysis are known to have higher risk for gastrointestinal (GI) bleeding. However, data on mild to moderate CKD, particularly elevated albuminuria, are limited.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Among 11,088 participants in the Atherosclerosis Risk in Communities (ARIC) Study, we investigated the association of eGFR and urinary albumin-to-creatinine ratio (ACR) with risk for hospitalization with GI bleeding. Kidney measures were assessed at visit four (1996-1998), and follow-up was continued through 2011.

RESULTS

During a median follow-up of 13.9 years, 686 first incident hospitalizations with GI bleeding were observed (incidence rate, 4.9 per 1000 person-years [95% confidence interval (95% CI), 4.5 to 5.3]). Multivariable Cox proportional hazards models revealed that both lower eGFR and higher ACR were associated with higher risk for GI bleeding. With eGFR≥90 ml/min per 1.73 m2 as a reference, risk for GI bleeding was significant in moderately decreased eGFR of 30-59 ml/min per 1.73 m2 (hazard ratio [HR], 1.51; 95% CI, 1.13 to 2.02), and was highest in severely decreased eGFR<30 ml/min per 1.73 m2 (HR, 7.06; 95% CI, 3.91 to 12.76). Compared with ACR<10 mg/g, risk for GI bleeding became significantly higher in mild albuminuria with ACR 10-29 mg/g (HR, 1.36; 95% CI, 1.08 to 1.69), and was nearly double in moderate and severe albuminuria (HR, 2.13; 95% CI, 1.66 to 2.71 for ACR 30-299 mg/g, and HR, 2.07; 95% CI, 1.33 to 3.22 for ACR≥300 mg/g). These results were largely consistent in demographic and clinical subgroups and independent of incident cardiovascular events or dialysis during follow-up.

CONCLUSIONS

Individuals with even mild to moderate CKD warrant clinical attention regarding the risk of hospitalization with GI bleeding.

The Risk of Major Hemorrhage with CKD

New staging systems for CKD account for both reduced eGFR and albuminuria; whether each measure associates with greater risk of hemorrhage is unclear. In this retrospective cohort study (2002-2010), we grouped 516,197 adults ≥40 years old by eGFR (≥90, 60 to <90, 45 to <60, 30 to <45, 15 to <30, or <15 ml/min per 1.73 m(2)) and urine albumin-to-creatinine ratio (ACR; >300, 30-300, or <30 mg/g) to examine incidence of hemorrhage. The 3-year cumulative incidence of hemorrhage increased 20-fold across declining eGFR and increasing urine ACR groupings (highest eGFR/lowest ACR: 0.5%; lowest eGFR/highest ACR: 10.1%). Urine ACR altered the association of eGFR with hemorrhage (P<0.001). In adjusted models using the highest eGFR/lowest ACR grouping as the referent, patients with eGFR=15 to <30 ml/min per 1.73 m(2) had adjusted relative risks of hemorrhage of 1.9 (95% confidence interval [95% CI], 1.5 to 2.4) with the lowest ACR and 3.7 (95% CI, 3.0 to 4.5) with the highest ACR. Patients with the highest eGFR/highest ACR had an adjusted relative risk of hemorrhage of 2.3 (95% CI, 1.8 to 2.9), comparable with the risk for patients with the lowest eGFR/lowest ACR. The associations attenuated but remained significant after adjustment for anticoagulant and antiplatelet use in patients ≥66 years old. The risk of hemorrhage differed by urine ACR in high risk subgroups. Our data show that declining eGFR and increasing albuminuria each independently increase hemorrhage risk. Strategies to reduce hemorrhage events among patients with CKD are warranted.