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Association of intermittent versus continuous hemodialysis modalities with mortality in the setting of acute stroke among patients with end-stage renal disease
  1. Michael C Morgan1,
  2. Jennifer L Waller2,
  3. Wendy B Bollag3,4,
  4. Stephanie L Baer1,5,
  5. Sarah Tran1,
  6. Mufaddal F Kheda6,
  7. Lufei Young7,
  8. Sandeep Padala1,
  9. Budder Siddiqui1,
  10. Azeem Mohammed1
  1. 1 Department of Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
  2. 2 Department of Population Health Science, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
  3. 3 Department of Physiology, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
  4. 4 Research, Charlie Norwood VA Medical Center, Augusta, Georgia, USA
  5. 5 Infection Control and Epidemiology, Charlie Norwood VA Medical Center, Augusta, Georgia, USA
  6. 6 Southwest Georgia Nephrology, Albany, Georgia, USA
  7. 7 Department of Physiological and Technological Nursing, Augusta University, Augusta, Georgia, USA
  1. Correspondence to Dr Wendy B Bollag, Department of Physiology, Medical College of Georgia at Augusta University, Augusta, GA, 30912, USA; wbollag{at}augusta.edu

Abstract

Patients with end-stage renal disease (ESRD) are 8–10 times more likely to suffer from a stroke compared with the general public. Despite this risk, there are minimal data elucidating which hemodialysis modality is best for patients with ESRD following a stroke, and guidelines for their management are lacking. We retrospectively queried the US Renal Data System administrative database for all-cause mortality in ESRD stroke patients who received either intermittent hemodialysis (IHD) or continuous renal replacement therapy (CRRT). Acute ischemic stroke and hemorrhagic stroke were identified using the International Classification of Diseases 9th Revision (ICD-9)/ICD-10 codes, and hemodialysis modality was determined using Healthcare Common Procedure Coding System (HCPCS) codes. Time to death from the first stroke diagnosis was the outcome of interest. Cox proportional hazards modeling was used, and associations were expressed as adjusted HRs. From the inclusion cohort of 87,910 patients, 92.9% of patients received IHD while 7.1% of patients received CRRT. After controlling for age, race, sex, ethnicity, and common stroke risk factors such as hypertension, diabetes, tobacco use, atrial fibrillation, and hyperlipidemia, those who were placed on CRRT within 7 days of a stroke had an increased risk of death compared with those placed on IHD (HR=1.28, 95% CI 1.25 to 1.32). It is possible that ESRD stroke patients who received CRRT are more critically ill. However, even when the cohort was limited to only those patients in the intensive care unit and additional risk factors for mortality were controlled for, CRRT was still associated with an increased risk of death (HR=1.32, 95% CI 1.27 to 1.37). Therefore, further prospective clinical trials are warranted to address these findings.

  • stroke
  • dialysis solutions

Data availability statement

Data are available upon reasonable request. The USRDS data set used for this study can be requested from the National Institute of Diabetes and Digestive and Kidney Diseases using the following link: https://www.usrds.org/for-researchers/simple-data-requests/.

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Data availability statement

Data are available upon reasonable request. The USRDS data set used for this study can be requested from the National Institute of Diabetes and Digestive and Kidney Diseases using the following link: https://www.usrds.org/for-researchers/simple-data-requests/.

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Footnotes

  • Twitter @StephanieBaerMD

  • Presented at This work has been previously presented at the 2021 American Federation of Medical Research Southern Regional Meeting.

  • Contributors MCM, JLW, WBB, SLB, ST, MFK, LY, SP, BS and AM conceptualized the project. JLW created the analysis data set and curated and created the models to analyze the data. MCM, JLW, WBB and AM obtained and interpreted the data. MCM, JLW, WBB and AM wrote the original draft. MCM, JLW, WBB, SLB, ST, MFK, LY, SP, BS and AM reviewed and edited the manuscript. MCM, JLW, WBB and AM visualized the data. JLW, SLB, WBB and AM supervised the project. WBB and AM administered the project and MFK and AM acquired funding to support the study. WBB serves as the guarantor, accepting full responsibility for the overall content.

  • Funding The Dialysis Clinic (project number C-3953 (081-East Albany)) funded this project. The Medical College of Georgia Medical Scholars Program supported this project.

  • Disclaimer The contents of this article do not represent the views of the Department of Veterans Affairs or the United States Government. The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy or interpretation of the United States Government.

  • Competing interests SLB is an Editorial Board member for the Journal of Investigative Medicine.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.