Global Trends of Stroke in Haemodialysis (2000-2012): A Retrospective Cohort Study of the Monitoring Dialysis Outcomes Initiative

Background Stroke remains a key cause of death&morbidity in HD patients(pts) that exhibit stroke rates 10-12x higher than the general population(GP). Primary&secondary prevention strategies have progressively reduced the burden of stroke in the GP but it is unclear if this trend has transposed to HD pts globally. Methods We studied 4,388 strokes in 150k pts. The MONDO Initiative consists of HD pts from 41 countries [von Gersdorff GD et al.]. All adult pts from the MONDO database [2000-2012] were studied with fatal&non-fatal hospitalized stroke defined by ICD-9&10 codes and excluded transient ischemic attack. Results The overall incidence of stroke rose from 8.7-28.7/1k pt yrs. This compares to static rates worldwide in the GP[2.5-2.6/1k pt yrs,1990-2010] with falling rates in high-income countries. A sharper rise in hemorrhagic stroke rate was seen compared to ischemic stroke in HD pts[Fig], reflecting trends seen in younger age groups worldwide. Despite falling stroke mortality worldwide[1.4-1.1/1k pt yrs,1990-2012], there was a progressive rise in HD populations [1.5-10.5/1k pt yrs, 2000-2012]. These stroke trends occurred despite increasing treatment time[203-245 mins], better BP control[mean pre-HD BP 150/80-137/72mmHg] and falling ultrafiltration rates. Stroke rates remained high 3 months after HD started and continued to fall for 2 yrs, driven by ischemic stroke incidence and with stable hemorrhagic stroke rates. Conclusion There is a progressive rise in stroke incidence and mortality over time in HD pts globally which starkly contrasts with global trends. This appears to be driven predominantly with rising rates of hemorrhagic stroke which carries a higher case-fatality rate. Stroke rates are at their highest within the first year of HD and there is a pressing need to reduce stroke risk in a particularly vulnerable pts at an early stage.