Outcomes Following Ischemic Stroke in Older Patients With CKD Stages 4 and 5: A Retrospective Cohort Study
American Journal of Kidney Diseases(2020)
摘要
Rationale & Objective: The associations be-tween ischemic stroke and time to dialysis initiation and/or death in adults with late-stage chronic kidney disease (CKD) have not been explored. We sought to measure the rate and factors associated with stroke in CKD stages 4 and 5 (CKD4-5) and assess the association of stroke with initiation of dialysis and death.Study Design: Retrospective cohort.Setting & Participants: Patients with CKD4-5 in Medicare 2007 to 2014.Exposure or Predictor: Ischemic stroke in CKD4-5.Outcomes: Initiation of maintenance dialysis or death.Analytical Approach: Cox proportional hazard modeling assessed factors associated with ischemic stroke. A matched analysis (stroke/no stroke) estimated the cumulative incidence of incident kidney failure and death, treated as competing events. Simulations using a state transition model determined differences in expected time to kidney failure or death and death alone for patients with and without stroke with CKD5.Results: 123,251 patients with CKD4 and 22,054 with CKD5 were identified. Mean ages were 81.0 and 79.2 years, respectively. Female sex (HRs of 1.21 [95% CI, 1.12-1.31] and 1.39 [95% CI, 1.04-1.8 6] for CKD4 and CKD5, respectively) and black race (HRs of 1.25 [95% CI, 1.12-1.3 9] and 1.12 [95% CI, 0.80-1.58] for CKD4 and CKD5, respectively) were factors associated with ischemic stroke. Rates for 30-day mortality were 13.3% and 18.8%, and for 1-year mortality, 40.0% and 38.2%. For patients with CKD5, kidney failure or death occurred an average of 3.6 months sooner for patients with an ischemic stroke, and death (irrespective of kidney failure), a mean of 24.3 months sooner.Limitations: Study design cannot determine causality; lack of data for stroke severity.Conclusions: Female sex and black race were associated with increased risk for stroke in CKD4 and CKD5. In CKD5, stroke was associated with a shorter time to kidney failure or death by nearly 4 months, and to death, by more than 2 years.
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关键词
Chronic kidney disease (CKD),incident kidney failure,ischemic stroke,mortality,advanced CKD,cardiovascular event,CKD progression,dialysis initiation
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