Appraising Stroke Risk in Maintenance Hemodialysis Patients: A Large Single-Center Cohort Study
Appraising Stroke Risk in Maintenance Hemodialysis Patients: A Large Single-Center Cohort Study
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DOI：
10.1053/j.ajkd.2011.07.016
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发表时间：
2012-02-01
影响因子：
13.2
通讯作者：
Duncan, Neill
中科院分区：
文献类型：
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作者：
Power, Albert;Chan, Kakit;Duncan, Neill
背景：血液透析患者的卒中发病率是普通人群的10倍，且与较差的预后有关。研究设计：回顾性的单中心队列研究。设置和参与者：从2002年1月1日到2009年6月1日，在一个中心建立了2,384名维持性血液透析患者。预测因素：患者的人口学特征，合并症。结果：急性卒中的发生率(国际疾病分类第9版，第430,431,432.9,433.1和434.1，神经影像符合证据)，患者存活率。测量：累积患者存活率，急性致命性和非致命性卒中的发生率。结果：在9,541个患者的总随访年中发生127个卒中。首次(事件)卒中发生率为14.9/1000病人年(95%CI，12.2-17.9)，与出血性亚型(11.2vs3.7/1000病人年)相比，缺血性卒中占主导地位。54%的出血性卒中发生在南亚族裔患者，而缺血性卒中主要发生在白人患者(45%)。多因素分析显示，糖尿病(HR，1.92；95%CI，1.29~2.85；P=0.001)和既往脑血管疾病(HR，4.54；95%CI，3.07~6.72；P<；0.001)是发生脑血管意外的独立危险因素。急性卒中与较差的患者存活率(HR，3.26；95%CI，2.47-4.3；P<；0.001)和总的一年死亡率为24%有关，而在有出血事件的患者中，这一点更为严重(缺血亚型患者的死亡率为39%比19%)。多因素分析显示血清白蛋白3.5g/L(HR，0.38；95%CI，0.19~0.76；P=0.007)和C反应蛋白(C-反应蛋白)3.0 mg/L(HR，1.36；95%CI，1.12~1.64；P=0.002)影响卒中后生存。严格的高血压管理，更好地认识血液透析抗凝，以及大规模的干预性研究是指导这一重大疾病预防和治疗的迫切需要。我是J·肯尼·迪斯。59(2)：249-257。(C)2012年，由国家肾脏基金会公司提供。
Background: Stroke incidence in hemodialysis patients is up to 10 times greater than in the general population and is associated with a worse prognosis. Factors influencing stroke risk by subtype and subsequent prognosis are poorly described in the literature.Study Design: Retrospective single-center cohort study.Setting & Participants: 2,384 established maintenance hemodialysis patients at a single center from January 1, 2002, to June 1, 2009.Predictor: Patient demographics, comorbid conditions.Outcomes: Incidence of acute stroke (International Classification of Diseases, 9th Revision codes 430, 431, 432.9, 433.1, and 434.1 with evidence of compatible neuroimaging), patient survival.Measurements: Cumulative patient survival, incidence of acute fatal and nonfatal stroke.Results: 127 strokes occurred during 9,541 total patient-years of follow-up. First (incident) stroke occurred at a rate of 14.9/1,000 patient years (95% CI, 12.2-17.9) with a predominance of ischemic compared with hemorrhagic subtypes (11.2 vs 3.7/1,000 patient-years). 54% of hemorrhagic strokes occurred in patients of South Asian ethnicity compared with ischemic strokes, which occurred predominantly in white patients (45% of events). Diabetes mellitus (HR, 1.92; 95% CI, 1.29-2.85; P = 0.001) and prior cerebrovascular disease (HR, 4.54; 95% CI, 3.07-6.72; P < 0.001) were independently associated with incident cerebrovascular accident on multivariate analysis. Acute stroke was associated with worse patient survival (HR, 3.26; 95% CI, 2.47-4.30; P < 0.001) and overall 1-year mortality of 24%, which was significantly worse in patients with hemorrhagic events (39% vs 19% mortality for ischemic subtypes). Serum albumin level >3.5 g/L (HR, 0.38; 95% CI, 0.19-0.76; P = 0.007) and C-reactive protein level >3.0 mg/l (HR, 1.36; 95% CI, 1.12-1.64; P = 0.002) influenced survival after stroke on multivariate analysis.Limitations: Retrospective analysis of data cannot prove causality.Conclusions: The high incidence of stroke in hemodialysis patients is associated with high mortality, especially hemorrhagic subtypes. Strict management of hypertension, better appreciation of hemodialysis anticoagulation, and large-scale interventional studies are urgently required to direct prevention and treatment of this significant disease. Am J Kidney Dis. 59(2):249-257. (C) 2012 by the National Kidney Foundation, Inc.