An update on hemorrhagic stroke in CKD
In this brief review, published in the Journal of the Association of Physicians of India, the authors discuss about the magnitude of hemorrhagic stroke, important risk factors and outcomes in predialysis and dialysis setting and its important preventive and treatment strategy.

Stroke is the third leading cause of cardiovascular disease death among persons with end-stage kidney disease (ESKD) on dialysis. As compared with the general population, stroke incidence rates and stroke mortality rates are increased 6- to 10-fold among patients on dialysis. The risk of hemorrhagic stroke has been reported to be higher than ischemic stroke in hemodialysis (HD) patients when compared to peritoneal dialysis (PD) patients, though this has not been consistently the case, especially in recent studies.

Chronic kidney disease (CKD) is associated with an over representation of traditional cardiovascular risk factors and an increased risk of stroke. Hypertension continues to be the major modifiable risk factor for both ischemic and hemorrhagic stroke with risk increasing with worsening systolic and diastolic blood pressure control.

In addition to shared risk factors, this higher cerebrovascular risk is mediated by several CKD-associated mechanisms including platelet dysfunction, coagulation disorders, endothelial dysfunction, inflammation and increased risk of atrial fibrillation (AF). Posterior circulation strokes involving the vertebrobasilar system occur more commonly in patients on dialysis than in the general population.

This suggests screening for carotid artery disease may not be as effective as stroke prevention strategy in patients on dialysis relative to the general population. Kidney transplantation is associated with 30% lower risk for stroke or transient ischemic attack (TIA) compared with patients remaining on the transplant waiting list, whereas allograft failure increases the risk for stroke or TIA by 50%.

Among patients who experienced an intracerebral hemorrhage, patients with CKD had a 2- to 3-fold higher likelihood of cerebral microbleeds, a marker of lipohyalinosis or amyloid angiopathy, compared to patients without CKD. This association was stronger among blacks than among whites.

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