Stroke in dialysis and chronic kidney disease

Renal impairment is a potent risk factor for stroke that is a leading cause of morbidity and mortality worldwide. Dialysis patients experience a 10-fold higher incidence, with case fatality rates reaching 90%. It is important to understand the factors predisposing to stroke in patients with chronic kidney disease (CKD) coupled with an appreciation of preventative strategies.

The heightened risk of stroke in CKD represents the interplay of the vascular comorbidities that cluster with renal impairment as well as pathology inherent in uremia, such as accelerated vascular calcification and the malnutrition-inflammation-atherosclerosis syndrome. These factors are most marked in hemodialysis where stroke rates peak at 10-35/1,000 patient years and where hemorrhagic stroke accounts for 20-30% of all events. Older age, hypertension, diabetes and established cerebrovascular disease are all risk factors for stroke with dialysis initiation constituting the highest risk period. Patients with CKD stages 3-5D have worse survival as well as diminished functional outcomes following stroke. Thrombolytic therapy for acute stroke appears safe in all stages of CKD although the therapeutic effect may be attenuated. Control of hypertension and the use of antiplatelet agents form the mainstay of stroke prevention. The benefit of antiplatelet therapies and oral anticoagulants must be balanced against the real risks of bleeding that are most evident in dialysis cohorts.

Understanding the risks and benefits of established stroke treatments is vital in patients with CKD, especially in those on dialysis therapies who are at highest risk of adverse outcomes.