Inequality in Care and Differences in Outcome Following Stroke in People With ESRD

Abstract

Introduction: Stroke rate and mortality are greater in individuals with end-stage renal disease (ESRD) than in those without ESRD. We examined discrepancies in stroke care in ESRD patients and their influence on mortality.

Methods: This is a national record linkage cohort study of hospitalized stroke individuals from 2005 to 2013. Presentation, measures of care quality (admission to stroke unit, swallow assessment, antithrombotics, or thrombolysis use), and outcomes were compared in those with and without ESRD after propensity score matching (PSM). We examined the effect of being admitted to a stroke unit on survival using Kaplan-Meier and Cox survival analyses.

Results: A total of 8757 individuals with ESRD and 61,367 individuals with stroke were identified. ESRD patients (n =486) experienced stroke over 34,551.9 patient-years of follow-up; incidence rates were 25.3 (dialysis) and 4.5 (kidney transplant)/1000 patient-years. After PSM, dialysis patients were less likely to be functionally independent (61.4% vs. 77.7%; P < 0.0001) before stroke, less frequently admitted to stroke units (64.6% vs. 79.6%; P < 0.001), or to receive aspirin (75.3% vs. 83.2%; P = 0.01) than non-ESRD stroke patients. There were no significant differences in management of kidney transplantation patients. Stroke with ESRD was associated with a higher death rate during admission (dialysis 22.9% vs.14.4%, P = 0.002; transplantation: 19.6% vs. 9.3%; P = 0.034). Managing ESRD patients in a stroke unit was associated with a lower risk of death at follow-up (hazard ratio: 0.68; 95% confidence interval: 0.55-0.84).

Conclusion: Stroke incidence is high in ESRD. Individuals on dialysis are functionally more dependent before stroke and less frequently receive optimal stroke care. After a stroke, death is more likely in ESRD patients. Acute stroke unit care may be associated with lower mortality.

Keywords: ESRD; dialysis; stroke; transplantation outcomes.

Figure 1

Kaplan-Meier estimator survival curves demonstrating time to death after stroke in the matched population without end-stage renal disease (ESRD), transplant recipients. and dialysis patients. Log-rank test; P < 0.0001.

Figure 2

Kaplan-Meier survival curves demonstrating time to death after following stroke in both end-stage renal disease (ESRD) and non-ESRD populations, split by source of stroke diagnosis: non-ESRD Scottish Stroke Care Audit (SSCA), non-ESRD Scottish Morbidity Records 01 (SMR01), ESRD population SSCA, and ESRD population SMR01. Log-rank test; P < 0.0001.

Figure 3

Kaplan-Meier survival curves demonstrating time to death after stroke in patients with end-stage renal disease and the effect of admission to an acute stroke unit (ASU). Log-rank test P < 0.0001.

Figure S3

Kaplan-Meier survival estimator demonstrating time to death following stroke, split by matched stroke population without end-stage renal disease (ESRD), kidney transplant recipients, peritoneal dialysis patients, and hemodialysis patients. Log-rank test; P < 0.0001.