Prevalence and Impact on Stroke in Patients Receiving Maintenance Hemodialysis versus Peritoneal Dialysis: A Prospective Observational Study

Comparative Outcomes of Peritoneal and Hemodialysis in ESRD Patients with STEMI: A National Inpatient Sample Analysis (2016-2020)

End-stage renal disease (ESRD) patients are at increased risk of mortality, particularly due to cardiovascular events such as acute myocardial infarction. Hemodialysis and peritoneal dialysis are the two main treatment modalities for ESRD patients. Using data from the National Inpatient Sample (NIS) database, we conducted a retrospective study involving 25,435 ESRD patients diagnosed with ST-elevation myocardial infarction (STEMI) between 2016 and 2020, categorized by their dialysis regimen. Our analysis revealed comparable mortality rates between peritoneal dialysis (PD) and hemodialysis (HD) patients, but lower hospitalization costs and fewer complications among PD recipients. Over five years, we observed a notable decrease in STEMI mortality despite increased STEMI cases among HD patients. Conversely, HD patients experienced increased hospital stays and associated costs over the study period than PD patients, who demonstrated stable trends. This study highlights the implications of dialysis modality selection in managing costs and reducing morbidity among STEMI patients with ESRD.

Prevalence of stroke among patients with chronic kidney disease, Taif, Saudi Arabia

OBJECTIVES

To evaluate the prevalence of stroke among chronic kidney disease (CKD) patients in Taif, Saudi Arabia.

METHODS

A multicentric retrospective study was carried out from May 2021 to August 2022 on 4 dialysis centers in Taif, Saudi Arabia. With a total of 1857 CKD patients (aged ≥18 years old) participated in this study. Data were collected by reviewing patients' files.

RESULTS

Approximately 98.3% of the participants had severely decreased glomerular filtration rate. Approximately 49.1% of them were on dialysis; the majority of them (87.2%) underwent hemodialysis. The prevalence of stroke in these CKD patients was 8.3%. Ischemic stroke was the most frequently reported issue (81.2%). Ischemic stroke was comparatively more frequently observed in peritoneal dialysis patients (12.1%); whereas hemorrhagic stroke was more on hemodialysis patients with statistically significant association (p=0.029). However, there was no significant association between the prevalence of stroke and stages of CKD.

CONCLUSION

The prevalence of stroke in our cohort was 8.3%, and the majority of cases were ischemic strokes. Furthermore, ischemic strokes were more frequent in peritoneal dialysis patients, whereas hemorrhagic strokes occurred more frequently in hemodialysis patients with a statistically significant association.

Epidemiology and Risk Factors for Stroke in Chronic Kidney Disease: A Narrative Review

Patients with chronic kidney disease (CKD) have a higher risk ofboth ischemic and hemorrhagic stroke. This association appears to be partly independent from the higher prevalence of established risk factors for stroke in patients with CKD, including hypertension and atrial fibrillation. In the present review we aim to discuss the impact of CKD on the risk of stroke and stroke-related consequences, and explore the pathophysiology underpinning the increased risk of stroke in patients with CKD. We cover the clinical association between renal dysfunction and cerebrovascular disease including stroke, silent brain infarct, cerebral small vessel disease, microbleeds, and white matter hyperintensity, and discuss the underlying mechanisms.

Microemboli induced by air bubbles may be deposited in organs as a consequence of contamination during medical care

Background

Larger volumes of accidental air infused during medical care may end up as emboli while microbubbles of air are supposed to be absorbed and cause no harm. The aim of this autopsy study was to investigate if microbubbles of air accidently entering the bloodline may be detected as microemboli (ME) in tissue such as lungs, brain and heart. If so, do differences in prevalence exist between haemodialysis (HD) and amyotrophic lateral sclerosis (ALS) patients.

Methods

Included were data from 44 patients treated by medical healthcare before death. Twenty-five cases had been treated with chronic HD and 19 cases died from ALS. Since air in the bloodline activates coagulation, ME could appear. To discriminate between microbubbles caused by artificial contamination during autopsy versus microbubbles deposited in vivo, tissues were stained with a polyclonal fluorescent antibody against fibrinogen, fibrin and fragments E and D. Fluorescence staining was used to visualize ME counted within 25 microscopic fields (600×) of a tissue preparation. One tissue preparation was used if available from the lung, heart and frontal lobe of the brain and in five cases also the cerebellum.

Results

Microbubbles can be verified at autopsy as ME in the lung, heart and brain in tissue from patients exposed to more extensive medical care. There were significantly more ME in the lungs versus the heart or brain. Women had fewer ME than men. The HD group had a higher median of ME per section than the ALS group (lung: 6 versus 3, P = .007; heart: 2.5 versus 1, P = .013; brain: 7.5 versus 2, P = .001) and had more sections with ME findings than the ALS group (P = .002). A correlation existed between the time on HD (months) and ME in the lungs.

Conclusions

More ME were present in HD patients compared with those who suffered from ALS. Minimizing air contamination from syringes, infusions and bloodlines will decrease ME and subsequent tissue injury.

Epidemiology, thrombolytic management, and outcomes of acute stroke among patients with chronic kidney disease: a systematic review and meta-analysis

BACKGROUND

The relative frequency of ischemic versus hemorrhagic stroke among patients with chronic kidney disease (CKD) has not been clearly described. Moreover, no recent meta-analysis has investigated the outcomes of patients with CKD treated with thrombolysis for acute ischemic stroke. We conducted a systematic review and meta-analysis to estimate the proportion of stroke subtypes and the outcomes of thrombolysis in CKD.

METHODS

A PubMed, EMBASE and Cochrane literature research was conducted. The primary outcome was the proportion and incidence of ischemic versus hemorrhagic strokes among patients with CKD. In addition, we assessed the impact of CKD on disability, mortality, and bleeding among patients with acute ischemic stroke treated with thrombolysis. The pooled proportion and the risk ratio (RR) were estimated using a random-effects model.

RESULTS

Thirty-nine observational studies were included: 22 on the epidemiology of stroke types and 17 on the outcomes of thrombolysis in this population. In the main analysis (> 99,281 patients), ischemic stroke was more frequent than hemorrhagic among patients with CKD (78.3%, 95% confidence interval 73.3%-82.5%). However, among patients with kidney failure, the proportion of ischemic stroke decreased and was closer to that of hemorrhagic stroke: 59.8% (95% confidence interval 49.4%-69.4%). CKD was associated with worse clinical outcomes in patients with acute ischemic stroke compared with patients with preserved kidney function.

CONCLUSIONS

The relative frequency of hemorrhagic stroke seems to increase as kidney function declines. Among patients with acute ischemic stroke treated with thrombolysis, presence of CKD is associated with higher disability, mortality, and bleeding, compared with patients with preserved kidney function.

Expansion of Monocytic Myeloid-Derived Suppressor Cells in Patients Under Hemodialysis Might Lead to Cardiovascular and Cerebrovascular Events

Background

The specific mechanism of cardiovascular and cerebrovascular vasculopathy in the context of end-stage renal disease has not been elucidated. In the present study, we investigated the clinical impact of myeloid-derived suppressor cells (MDSCs) on hemodialysis patients and their mechanism of action.

Methods

MDSCs were tested among 104 patients undergoing hemodialysis and their association with overall survival (OS) and cardiovascular and cerebrovascular events was determined.

Results

Hemodialysis patients presented a significantly higher level of monocytic MDSCs (M-MDSCs) compared to healthy controls. M-MDSC were tested 3 months after first testing among 103 hemodialysis patients, with one patient not retested due to early death. The repeated results of M-MDSC levels were consistent with the initial results. Patients with persistent high level of M-MDSCs presented decreased OS, as well as increased stroke and acute heart failure events. As illustrated by multivariate Cox regression, M-MDSC was an independent predictor for OS and stroke events of hemodialysis patients. T cell proliferations were significantly abrogated by hemodialysis-related M-MDSCs in a dose-dependent manner. Besides, M-MDSCs presented higher levels of CXCR4 and VLA-4 compared to monocytes, which indicated their enhanced capability to be recruited to atherosclerotic lesions. The expression of arginase I and activity of arginase was also significantly raised in hemodialysis-related M-MDSCs. Human coronary arterial endothelial cells (HCAECs) presented increased capability to migration by coculture with M-MDSCs, compared with monocyte group. Arginase inhibitor and L-arginine abrogated the immune suppressive function and induction of HCAECs migration of hemodialysis related M-MDSC. Plasma IFN-γ, TNF-α and IL-6 were elevated in hemodialysis patients compared with healthy control. M-MDSC level was positively related to IL-6 level among hemodialysis patients. The plasma of hemodialysis patients induced M-MDSCs significantly compared with plasma from health donors. Besides, IL-6 neutralizing antibody significantly abrogated the induction. Neutralizing antibody of IFN-γ and TNF-α partially decreased the generation of arginase of the induced M-MDSC.

Conclusions

M-MDSCs were elevated in ESRD patients under hemodialysis, and they exhibited a strong association with the risk of cardiovascular and cerebrovascular diseases. Hemodialysis related M-MDSC presented enhanced recruitment to atherosclerotic lesions, promoted the migration of endothelial cells through exhaustion of local L-arginine.

Comparison of risk of stroke in patients treated with peritoneal dialysis and hemodialysis: a systematic review and meta-analysis

Objective: Accumulating evidence has demonstrated that dialysis patients are at increased risk for stroke. However, the impact of dialysis modalities on stroke risk remains controversial. We conducted a systematic review and meta-analysis to determine the effect of peritoneal dialysis (PD) and hemodialysis (HD) on stroke risk. Methods: A systematic search of PubMed, EMBASE, and Web of Science was performed to identify articles comparing the stroke outcomes of dialysis patients. Hazard ratios (HRs) with 95% confidence intervals (95% CIs) were extracted and synthesized to examine stroke outcomes, including ischemic stroke, hemorrhagic stroke, and overall stroke. Results: The search yielded five studies composed of 1,219,245 patients that were evaluated in the final analysis. The results showed that PD was associated with a lower risk for hemorrhagic stroke compared with HD (HR = 0.78; 95% CI: 0.69-0.88; p < 0.001). For ischemic stroke, the results showed that PD was associated with a higher risk compared with HD among the non-Asian patients (HR = 1.13; 95% CI: 1.05-1.23; p = 0.002), but there were no significant differences between PD and HD for the Asian patients. Similarly, there were no significant differences between the effects of the PD and HD approaches on overall stroke risk. Conclusions: We observed that PD patients were less likely to develop hemorrhagic stroke than HD patients, and the risk for ischemic stroke was significantly higher for PD patients than for HD patients among the non-Asian patients. However, our findings could be biased due to the heterogeneity of the included studies.

Cerebrovascular events in hemodialysis patients; a retrospective observational study

BACKGROUND

This study reports findings in subjects who underwent brain imaging for any reason, and examined factors influencing cerebrovascular events (CVEs) in hemodialysis (HD) patients.

METHODS

We reviewed the files of patients on HD between January 2015 and January 2018. A total of 432 patients who underwent HD for at least 5 months by the January 2015 and who were older than 18 years were included in the study; 264 had been examined by cerebral computed tomography or magnetic resonance imaging examination within the 3 years. Cerebrovascular pathology was detected in 139 of 264 patients.

RESULTS

Of the 139 patients, 65 (24.62%) had ischemic lesions, 25 (9.47%) had hemorrhagic lesions, and 49 (18.56%) had cerebral small vessel disease (CSVD). We compared recorded data and later clinical findings between patients with and those without CVEs. The cause of end-stage renal disease was diabetes in 58.5% of patients with ischemic lesions, 52% in those with hemorrhagic lesions, and 55% in those with CSVD (P < 0.05). Patients with cerebrovascular ischemia were older (P = 0.0001) and had lower serum creatinine (sCr) (P = 0.0001) and higher serum C-reactive protein (CRP) (P = 0.002) levels than normal subjects. Hemorrhagic patients were older (P = 0.003) and had lower sCr (P = 0.003) and serum predialysis potassium (P = 0.003) and parathyroid hormone (PTH) (P = 0.004) levels than normal subjects. Patients with CSVD were older (P < 0.0001) and had lower sCr (P < 0.0001), phosphorus (P < 0.007), and PTH (P < 0.013) and higher CRP (P < 0.002) levels than normal subjects.

CONCLUSIONS

HD patients with CVEs are older and typically have diabetes mellitus and lower sCr levels.

Serum lipoprotein(a) and risk of hemorrhagic stroke among incident peritoneal dialysis patients: a large study from a single center in China

Background: This retrospective study investigated whether baseline serum lipoprotein(a) (Lp(a)) may predict subsequent stroke in patients under chronic peritoneal dialysis (PD). Methods: Eight hundred and sixty incident PD patients, treated from 1 November 2005 to 28 February 2017, were enrolled, and followed until discontinuation of PD, death, or 31 May 2017. Hemorrhagic or ischemic stroke was the primary outcome. The population was stratified by baseline serum Lp(a) tertile. The risk of each stroke subtype was analyzed using the Cox proportional hazard models. Adjustments were made for: age; gender; history of stroke and hypertension; systolic blood pressure; lipid-lowering, antiplatelet and antihypertensive medications; laboratory profiles including hemoglobin, serum albumin, calcium, triglyceride, total and low-density lipoprotein cholesterol; and apolipoprotein A1. Results: Among the 860 participants, 19.3% and 4.1% had diabetes mellitus and a history of stroke, respectively. The median baseline serum Lp(a) was 328 (172-585) mg/L. After 28 (14-41) months of follow-up, 33 (3.84%) and 12 (1.40%) patients developed hemorrhagic and ischemic stroke, respectively. Participants in the highest Lp(a) tertile had a significantly lower risk of hemorrhagic stroke compared with those in the lowest tertile (hazard ratio (HR) 0.3, 95% confidence interval (CI) 0.1-0.86; p = .026); the rates of ischemic stroke were comparable among the tertiles. Each 10 mg/L rise in serum Lp(a) was associated with a 2% (95% CI 0.96-1; p = .033) lower risk of hemorrhagic stroke. Conclusions: Among patients with incident PD, a higher serum Lp(a) level may predict a lower risk of hemorrhagic stroke.

Renal replacement modality and stroke risk in end-stage renal disease-a national registry study

Background

The risk of stroke in end-stage renal disease (ESRD) on renal replacement therapy (RRT) is up to 10-fold greater than the general population. However, whether this increased risk differs by RRT modality is unclear.

Methods

We used data contained in the Scottish Renal Registry and the Scottish Stroke Care Audit to identify stroke in all adult patients who commenced RRT for ESRD from 2005 to 2013. Incidence rate was calculated and regression analyses were performed to identify variables associated with stroke. We explored the effect of RRT modality at initiation and cumulative dialysis exposure by time-dependent regression analysis, using transplant recipients as the reference group.

Results

A total of 4957 patients commenced RRT for ESRD. Median age was 64.5 years, 41.5% were female and 277 patients suffered a stroke (incidence rate was 18.6/1000 patient-years). Patients who had stroke were older, had higher blood pressure and were more likely to be female and have diabetes. On multivariable regression older age, female sex, diabetes and higher serum phosphate were associated with risk of stroke. RRT modality at initiation was not. On time-dependent analysis, haemodialysis (HD) exposure was independently associated with increased risk of stroke.

Conclusions

In patients with ESRD who initiate RRT, HD use independently increases risk of stroke compared with transplantation. Use of peritoneal dialysis did not increase risk on adjusted analysis.

The comparison of risk of stroke in patients with peritoneal dialysis and hemodialysis: A systematic review and meta-analysis

OBJECTIVE

Several studies have demonstrated that end-stage renal disease (ESRD) patients on dialysis are at higher risk for cerebrovascular events, especially those on hemodialysis. However, the risk of stroke in patients on peritoneal dialysis (PD) compared to those on hemodialysis (HD) remains unclear. We performed this meta-analysis to assess the risks of stroke in ESRD patients on PD compared to HD.

METHODS

A systematic review was conducted using MEDLINE, EMBASE, Cochrane databases from inception through January 2018 to identify studies that evaluated the risks of stroke (all types of stroke, ischemic stroke or hemorrhagic stroke) in ESRD patients on different dialysis modalities. Effect estimates from the individual study were extracted and combined using random-effect, generic inverse variance method of DerSimonian and Laird.

RESULTS

Fifteen cohort studies with a total of 1 289 572 ESRD patients (over 1 140 942 on HD and 122 534 on PD) were enrolled. Compared with HD, PD was associated with a significantly decreased risk of hemorrhagic stroke with pooled OR of 0.84 (95% CI: 0.76-0.92). However, there were no differences in risks of all types of stroke or ischemic stroke in those on PD compared to HD with pooled ORs of 1.06 (95% CI: 0.91-1.22) and 1.01 (95% CI: 0.80-1.18,), respectively.

CONCLUSIONS

PD status is associated with 16% lower risk of hemorrhagic stroke compared to HD, but the risks of all types of stroke and hemorrhagic stroke are not statistically different in PD patients when compared to HD patients.

Primary Prevention of Stroke in Chronic Kidney Disease Patients: A Scientific Update

BACKGROUND

Although chronic kidney disease (CKD) is an independent risk factor for stroke, official recommendations for the primary prevention of stroke in CKD are generally lacking.

SUMMARY

We searched PubMed and ISI Web of Science for randomised controlled trials, observational studies, reviews, meta-analyses and guidelines referring to measures of stroke prevention or to the treatment of stroke-associated risk factors (cardiovascular disease in general and atrial fibrillation (AF), arterial hypertension or carotid artery disease in particular) among the CKD population. The use of oral anticoagulation in AF appears safe in non-end stage CKD, but it should be individualized and preferably based on thromboembolic and bleeding stratification algorithms. Non-vitamin K antagonist oral anticoagulants with definite dose adjustment are generally preferred over vitamin K antagonists in mild and moderate CKD and their indications have started being extended to severe CKD and dialysis also. Aspirin, but not clopidogrel, has limited indications for reducing the risk for atherothrombotic events in CKD due to its increased bleeding risk. Carotid endarterectomy has shown promising results for stroke risk reduction in CKD patients with high-grade symptomatic carotid stenosis. The medical treatment of arterial hypertension in CKD often fails to efficiently lower blood pressure values, but recent data regarding the use of interventional procedures such as renal denervation, baroreflex activation therapy or renal artery stenting are encouraging. Key Messages: In the absence of clear guidelines and protocols, primary prevention of stroke in CKD patients remains a subtle art in the hands of the clinicians. Nevertheless, refraining CKD patients from standard therapies often worsens their prognosis.

Reverse epidemiology of elevated blood pressure among chronic hemodialysis black patients with stroke: a historical cohort study

Background

Stroke is the third leading cause of cardiovascular mortality in dialysis patients. The objective of this study was to assess the extent of stroke in chronic hemodialysis patients.

Methods

Historical cohort of patients enrolled in two hemodialysis (HD) centers from January 1, 2010 to December 31, 2011, including 191 patients (mean age 52 years, 68% men). Incidence curves and survival time analysis between the first day of HD and the end of the study were described by the Kaplan-Meier method. Independent stroke predictors were identified by multiple logistic regression analysis. P < 0.05 defined the level of statistical significance.

Results

12 incident stroke were recorded during the study period, with 1622.1 person-months (PM), a stroke incidence rate of 7.4 cases per 1000 PM (95% CI = 7.35–7.44) at the point date. The incidence of stroke at 6 months, 12 months and 24 months was 9.8%, 11.9% and 13%, respectively. Only the absence of arterial hypertension (RR = 5.7, 95% CI: 1.52–21.42) emerged as an independent determinant of stroke.

Conclusion

The high incidence of stroke in Kinshasa HD centers is partially explained by reverse epidemiology. Efforts must be made to understand this phenomenon in order to reduce its impact.

Assessment of the 10-year risk of cardiovascular disease among a group of patients on maintenance hemodialysis: A cross-sectional study from Cameroon

Objective

To assess the 10-year risk of cardiovascular disease and potential impacting factors among patients undergoing hemodialysis in Yaoundé, Cameroon.

Design

A cross-sectional study in January 2016.

Setting

Patients were recruited at the dialysis unit of the Yaoundé University Teaching Hospital, Cameroon.

Participants

These were hemodialysis patients aged 20 years and above, dialyzing in the above unit since at least 3 months and volunteering to be enrolled in the study.

Main outcome measures

The risk of cardiovascular disease was assessed using the Framingham risk score.

Results

We included 44 patients. The risk of cardiovascular disease ranged from less than 1% to more than 30% with a median of 12.3% (interquartile range 4.9–24.4). Twenty hemodialysis patients (45.5%) had a low risk of cardiovascular disease (<10%), 10 (22.7%), a moderate risk (10–20%), and 14 (31.8%) presented a high risk of cardiovascular disease (>20%). In multivariable linear regression analysis, duration on dialysis (adjusted β = 0.11; p = 0.003), number of weekly sessions of physical activity (adjusted β = −1.35; p = 0.018), fasting serum glucose levels (adjusted β = 4.22; p = 0.022), serum triglycerides levels (adjusted β = 5.94; p = 0.033), and serum urea levels (adjusted β = −2.08; p = 0.039) were independently impacting our patients’ risk of cardiovascular disease.

Conclusion

Around 55% of our study population presented a moderate or high risk of cardiovascular disease. Duration on dialysis, number of physical activity sessions per week, fasting serum glucose, serum triglycerides, and serum urea levels may impact our hemodialysis patients’ risk of cardiovascular disease.

Ancrod revisited: viscoelastic analyses of the effects of Calloselasma rhodostoma venom on plasma coagulation and fibrinolysis

Fibrinogen depletion via catalysis by snake venom enzymes as a therapeutic strategy to prevent or treat thrombotic disorders was utilized for over four decades, with ancrod being the quintessential agent. However, ancrod eventually was found to not be of clinical utility in large scale stroke trial, resulting in the eventual discontinuation of the administration of the drug for any indication. It was hypothesized that ancrod, possessing thrombin-like activity, may have unappreciated robust coagulation kinetics. Using thrombelastographic methods, a comparison of equivalent tissue factor initiated thrombin generation and Calloselasma rhodostoma venom (rich in ancrod activity) on plasmatic coagulation kinetics was performed. The venom resulted in thrombi that formed nearly twice as fast compared to thrombin formed clots, and there was no difference in fibrinolytic kinetics initiated by tissue-type plasminogen activator. In plasma containing iron and carbon monoxide modified fibrinogen, which may be found in patients at risk of stroke, the coagulation kinetic differences observed with venom was still more vigorous than that seen with thrombin. These phenomena may provide insight into the clinical failure of ancrod, and may serve as an impetus to revisit the concept of fibrinogen depletion via fibrinogenolytic enzymes, not those with thrombin-like activity.