Background and Purpose- Chronic kidney disease is strongly associated with stroke with various purported mechanisms proposed. Low glomerular filtration rate appears to be a risk factor for stroke ...independent of cardiovascular risk factors in epidemiological studies, but there has been no systematic assessment of the impact of more complete adjustment for blood pressure on the association. Methods- We did a systematic review to February 2018 (MEDLINE/EMBASE) for cohort studies or randomized controlled trials that reported stroke incidence in adults according to baseline estimated glomerular filtration rate. Study and participant characteristics and relative risks (RR) were extracted. Estimates were combined using a random-effects model. Heterogeneity was assessed by x
statistics and
and by subgroup strata and meta-regression. Results- We identified 168 studies reporting data on 5 611 939 participants with 115 770 stroke outcomes. Eighty-five studies (3 417 098 participants; 72 996 strokes) provided adequate data for meta-analysis of estimated glomerular filtration rate and stroke risk. Incident stroke risk was increased among participants with estimated glomerular filtration rate <60 mL/min per 1.73 m
(RR=1.73; 95% CI, 1.57-1.90;
<0.001), but there was substantial heterogeneity between studies (
<0.0001;
, 78.5%). Moreover, the association was reduced after adjustment for cardiovascular risk factors, with progressive attenuation on more thorough adjustment for hypertension: single baseline blood pressure measure (RR=1.63; CI, 1.34-1.99;
<0.001); history or treated hypertension (RR=1.35; CI, 1.24-1.46;
<0.001); multiple blood pressure measurements over months to years (RR=1.10; CI, 1.02-1.18;
=0.01). Conclusions- The association between chronic kidney disease and stroke appears to be highly dependent on the method of adjustment for hypertension. The apparently independent relationship between chronic kidney disease and stroke may be confounded by their shared association with long-term prior blood pressure.
In the past decade, there have been major improvements in the control of risk factors, acute stroke therapies, and rehabilitation after the availability of high-quality evidence and guidelines on ...best practices in the acute phase. In this changing landscape, we aimed to investigate the stroke admission rates, time trends, risk factors, and outcomes during the period of 2014-2019 using German nationwide data.
We obtained data of all acute stroke hospitalizations by the Federal Statistical Office. All hospitalized cases of adults (age 18 years or older) with acute stroke from the years 2014-2019 were analyzed regarding time trends, risk factors, treatments, morbidity, and in-hospital mortality according to stroke subtype (all-cause/ischemic/hemorrhagic).
Between 2014 and 2019, overall stroke hospitalizations in adults (median age = 76 years, IQR: 65-83 years) initially increased from 306,425 in 2014 to peak at 318,849 in 2017 before falling to again to 312,692 in 2019, whereas percentage stroke hospitalizations that resulted in death remained stable during this period at 8.5% in 2014 and 8.6% in 2019. In a multivariate model of 1,882,930 cases, the strongest predictors of in-hospital stroke mortality were hemorrhagic subtype (adjusted OR aOR = 3.06, 95% CI 3.02-3.10;
< 0.001), cancer (aOR = 2.11, 2.06-2.16;
< 0.001), congestive heart failure (aOR = 1.70, 1.67-1.73;
< 0.001), and lower extremity arterial disease (aOR = 1.76, 1.67-1.84;
< 0.001).
Despite recent advances in acute stroke care over the past decade, the percentage of stroke hospitalizations resulting in death remained unchanged. Further research is needed to determine how best to optimize stroke care pathways for multimorbid patients.
Chronic kidney disease is strongly associated with an increased risk of stroke, small vessel disease, and vascular dementia. Common vascular factors for stroke, such as hypertension, diabetes, and ...atrial fibrillation, are more prevalent in patients with chronic kidney disease, accounting for this association. However, factors unique to these patients, such as uremia, oxidative stress, and mineral and bone abnormalities, as well as dialysis-related factors are also believed to contribute to risk. Despite improvements in stroke treatment and survival in the general population, the rate of improvement in patients with chronic kidney disease, especially those who are dialysis dependent, has lagged behind. There is a lack of or conflicting evidence that those with renal disease, particularly when advanced or older, consistently derive benefit from currently available preventive and therapeutic interventions for stroke in the general population. In this review, we explore the complexities and challenges of these interventions in the population with renal disease.
Chronic kidney disease (CKD) is a rapidly rising global health burden that affects nearly 40% of older adults. Epidemiologic data suggest that individuals at all stages of chronic kidney disease ...(CKD) have a higher risk of developing cognitive disorders and dementia, and thus represent a vulnerable population. It is currently unknown to what extent this risk may be attributable to a clustering of traditional risk factors such as hypertension and diabetes mellitus leading to a high prevalence of both symptomatic and subclinical ischaemic cerebrovascular lesions, or whether other potential mechanisms, including direct neuronal injury by uraemic toxins or dialysis-specific factors could also be involved. These knowledge gaps may lead to suboptimal prevention and treatment strategies being implemented in this group. In this review, we explore the mechanisms of susceptibility and risk in the relationship between CKD and cognitive disorders.
Background
Proteinuria has emerged as an important vascular risk factor for adverse cardiovascular events including stroke. Hypertension has been proposed as the principal confounder of this ...relationship but its role has not been systematically examined.
Aim
We aimed to determine if proteinuria remains an independent predictor of stroke after more complete adjustment for blood pressure.
Summary of review
We performed a systematic review, searching MEDLINE and EMBASE (to February 2018) for cohort studies or randomized controlled trials that reported stroke incidence in adults according to baseline proteinuria ± glomerular filtration rate. Study and participant characteristics and relative risks were extracted. Estimates were combined using a random effects model. Heterogeneity was assessed by χ
2
statistics and I2, and by subgroup strata and meta-regression, with a particular focus on the impact of more complete adjustment for blood pressure on the association. The quality of cohort studies and post hoc analyses was assessed using the Newcastle–Ottawa Scale. We identified 38 studies comprising 1,735,390 participants with 26,405 stroke events. Overall, the presence of any level of proteinuria was associated with greater stroke risk (18 studies; pooled crude relative risk 2.00, 95%CI 1.63–2.46; p < 0.001) even after adjustment for established cardiovascular risk factors (33 studies; pooled adjusted relative risk 1.72, 1.51–1.95; p < 0.001), albeit with considerable heterogeneity between studies (p < 0.001; I2 = 77.3%). Moreover, the association did not substantially attenuate with more thorough adjustment for hypertension: single baseline blood pressure measure (10 studies; pooled adjusted relative risk = 1.92, 1.39–2.66; p < 0.001); history or treated hypertension (four studies; pooled adjusted relative risk = 1.76, 1.13–2.75, p = 0.013); multiple blood pressure measurements over months to years (four studies; relative risk = 1.68, 1.33–2.14; p < 0.001).
Conclusions
Even after extensive adjustment for hypertension, proteinuria is strongly and independently associated with incident stroke risk, possibly indicating a shared renal and cerebral susceptibility to vascular injury that is not fully explained by traditional vascular risk factors.
Individuals with chronic kidney disease (CKD) appear to be at increased risk of cognitive impairment, with both vascular and neurodegenerative mechanisms postulated. To explore the vascular ...hypothesis, we studied the association between CKD and dementia before and after TIA and stroke.
In a prospective, population-based cohort study of TIA and stroke (Oxford Vascular Study; 2002-2012), pre-event and new postevent dementia were ascertained through direct patient assessment and follow-up for 5 years, supplemented by review of hospital/primary care records. Associations between pre-event dementia and CKD (defined as an estimated glomerular filtration rate eGFR <60 mL/min/1.73 m
) were examined using logistic regression and between postevent dementia and CKD using Cox and competing risk regression models, adjusted for age, sex, education, stroke severity, prior stroke, white matter disease, diabetes mellitus, and dysphasia.
Among 2,305 patients with TIA/stroke (median interquartile range age, 77 67-84 years, 1,133 49% male, 688 30% TIA), 1,174 (50.9%) had CKD. CKD was associated with both pre-event (odds ratio OR 2.04 95% confidence interval (CI) 1.52-2.72;
< 0.001) and postevent dementia (hazard ratio HR 2.01 95% CI 1.65-2.44;
< 0.001), but these associations attenuated after adjustment for covariates (OR 0.92 0.65-1.31;
= 0.65 and HR 1.09 0.85-1.39;
= 0.50). The results were similar when a competing risk model was used (subdistribution HR SHR 1.74 1.43-2.12;
< 0.001, attenuating to 1.01 0.78-1.33;
= 0.92 with adjustment). CKD was more strongly associated with late (>1 year) postevent dementia (SHR 2.32 1.70-3.17;
< 0.001), particularly after TIA and minor stroke (SHR 3.08 2.05-4.64;
< 0.001), but not significantly so after adjustment (SHR 1.53 0.90-2.60;
= 0.12).
In patients with TIA and stroke, CKD was not independently associated with either pre- or postevent dementia, suggesting that renal-specific mechanisms are unlikely to play an important role in aetiology.
The global health burden of chronic kidney disease is rapidly rising, and chronic kidney disease is an important risk factor for cerebrovascular disease. Proposed underlying mechanisms for this ...relationship include shared traditional risk factors such as hypertension and diabetes, uremia-related nontraditional risk factors, such as oxidative stress and abnormal calcium-phosphorus metabolism, and dialysis-specific factors such as cerebral hypoperfusion and changes in cardiac structure. Chronic kidney disease frequently complicates routine stroke risk prediction, diagnosis, management, and prevention. It is also associated with worse stroke severity, outcomes and a high burden of silent cerebrovascular disease, and vascular cognitive impairment. Here, we present a summary of the epidemiology, pathophysiology, diagnosis, and treatment of cerebrovascular disease in chronic kidney disease from the Kidney Disease: Improving Global Outcomes Controversies Conference on central and peripheral arterial disease with a focus on knowledge gaps, areas of controversy, and priorities for research.
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