Stroke and its implications across the spectrum of chronic kidney disease

 描述(由申请者提供)：拟议的项目将解决与国家糖尿病、消化和肾脏疾病研究所(NIDDK)的使命高度相关的重要公共卫生问题，涉及晚期慢性肾脏疾病(即CKD 4期和5期)和需要透析的终末期肾病(ESRD)患者的中风负担和中风相关临床结果。在世界范围内，数百万患者患有CKD 4-5和需要透析的终末期肾病，这个数字预计在未来几十年将大幅增长。中风在这类患者中很常见，但许多与中风相关的问题仍未得到探索。拟议项目的目标是：(1)确定随着肾脏疾病的恶化，卒中发生率如何变化；(2)创建动态风险计算器，以量化卒中后死亡、复发卒中和透析存活的相互竞争的风险；(3)通过测定卒中后出院与前往熟练护理机构的比率、卒中后30天和90天全原因再住院率以及与这些结果相关的因素，量化卒中后的临床病程；以及(4)探讨目前如何使用电子心律监测设备来检测心律失常，以改善CKD患者的初级卒中预防。这项工作将通过使用美国肾脏数据系统以及医疗保险和医疗补助服务中心提供的全面管理数据库来创建CKD和透析患者的大型回溯性队列来完成。多变量和竞争风险统计技术将被用来对各种风险因素和临床重要结果之间的关系进行建模，从而做出临床推断，并产生关键信息，这些信息可用于为患者和医生之间关于中风对患者健康状况的影响的对话提供信息。

 DESCRIPTION (provided by applicant): The proposed project will address important public health questions, highly relevant to the mission of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), about stroke burden and stroke-related clinical outcomes in patients with advanced chronic kidney disease (i.e., CKD stages 4 and 5) and with dialysis-requiring end stage renal disease (ESRD). Worldwide, several million patients have CKD 4-5 and dialysis-requiring ESRD, a number which is expected to grow substantially in coming decades. Stroke is common in such patients, but many stroke-related questions remain unexplored. The aims of the proposed project are to (1) determine how stroke rates change as kidney disease worsens; (2) create a dynamic risk calculator to quantify the competing risks of death, recurrent stroke, and survival on dialysis following a stroke; (3) quantify the post-stroke clinical course by determining rates of discharge to home versus to a skilled nursing facility afte a stroke, rates of 30- and 90-day all-cause hospital readmissions after stroke, and the factors associated with these outcomes; and (4) explore how electronic heart rhythm-monitoring devices are currently used for the detection of arrhythmias in order to improve primary stroke prevention in CKD patients. The work will be accomplished by creating large, retrospective cohorts of CKD and dialysis patients via use of comprehensive administrative databases provided by the United States Renal Data System and the Centers for Medicare and Medicaid Services. Multivariable and competing-risk statistical techniques will be used to model relationships between various risk factors and clinically- important outcomes, permitting clinical inferences to be made and generating key information which can be used to inform conversations between patients and physicians about the implications of stroke on patient health status.