The Association of Atrial Fibrillation and Ischemic Stroke in Patients on Hemodialysis: A Competing Risk Analysis.

Autor:	Findlay M; Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK.; The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, UK., MacIsaac R; Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK., MacLeod MJ; Institute of Medical Sciences, University of Aberdeen, Foresterhill, UK.; On Behalf of the Scottish Stroke Care Audit, Information Services Division, Edinburgh, UK., Metcalfe W; Department of Renal Medicine, Royal Infirmary of Edinburgh, UK.; On Behalf of the Scottish Renal Registry, Information Services Division, Glasgow, UK., Sood MM; Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada., Traynor JP; The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, UK.; On Behalf of the Scottish Renal Registry, Information Services Division, Glasgow, UK., Dawson J; Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK.; The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, UK., Mark PB; Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK.; The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, UK.
Jazyk:	angličtina
Zdroj:	Canadian journal of kidney health and disease [Can J Kidney Health Dis] 2019 Sep 27; Vol. 6, pp. 2054358119878719. Date of Electronic Publication: 2019 Sep 27 (Print Publication: 2019).
DOI:	10.1177/2054358119878719
Abstrakt:	Background: Stroke is common in patients with end-stage renal disease (ESRD) treated with hemodialysis (HD) and associated with high mortality rate. In the general population, atrial fibrillation (AF) is a major risk factor for stroke and therapeutic anticoagulation is associated with risk reduction, whereas in ESRD the relationship is less clear. Objective: The purpose of this study is to demonstrate the influence of AF on stroke rates and probability in those on HD following competing risk analyses. Design: A national record linkage cohort study. Setting: All renal and stroke units in Scotland, UK. Patients: All patients with ESRD receiving HD within Scotland from 2005 to 2013 (follow-up to 2015). Measurements: Demographic, clinical, and laboratory data were linked between the Scottish Renal Registry, Scottish Stroke Care Audit, and hospital discharge data. Stroke was defined as a fatal or nonfatal event and mortality derived from national records. Methods: Associations for stroke were determined using competing risk models: the cause-specific hazards model and the Fine and Gray subdistribution hazards model accounting for the competing risk of death in models of all stroke, ischemic stroke, and first-ever stroke. Results: Of 5502 patients treated with HD with 12 348.6-year follow-up, 363 (6.6%) experienced stroke. The stroke incidence rate was 26.7 per 1000 patient-years. Multivariable regression on the cause-specific hazard for stroke demonstrated age, hazard ratio (HR) (95% confidence interval [CI]) = 1.04 (1.03-1.05); AF, HR (95% CI) = 1.88 (1.25-2.83); prior stroke, HR (95% CI) = 2.29 (1.48-3.54), and diabetes, HR (95% CI) = 1.92 (1.45-2.53); serum phosphate, HR (95% CI) = 2.15 (1.56-2.99); lower body weight, HR (95% CI) = 0.99 (0.98-1.00); lower hemoglobin, HR (95% CI) = 0.88 (0.77-0.99); and systolic blood pressure (BP), HR (95% CI) = 1.01 (1.00-1.02), to be associated with an increased stroke rate. In contrast, the subdistribution HRs obtained following Fine and Gray regression demonstrated that AF, weight, and hemoglobin were not associated with stroke risk. In both models, AF was significantly associated with nonstroke death. Limitations: Our analyses derive from retrospective data sets and thus can only describe association not causation. Data on anticoagulant use are not available. Conclusions: The incidence of stroke in HD patients is high. The competing risk of "prestroke" mortality affects the relationship between AF and risk of future stroke. Trial designs for interventions to reduce stroke risk in HD patients, such as anticoagulation for AF, should take account of competing risks affecting associations between risk factors and outcomes. Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. (© The Author(s) 2019.)
Databáze:	MEDLINE
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