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

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

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

Results: 8,757 people with ESRD and 61,367 people with stroke were identified. 486 ESRD patients experienced stroke over 34,551.9 years follow-up; incidence rates 25.3 (dialysis) and 4.5 (kidney transplant)/ 1000 patient-years. Following 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 receive aspirin (75.3 vs 83.2%, p=0.01) than non-ESRD stroke patients. There were no significant differences in management of kidney transplant patients. Stroke with ESRD associated with higher death rate during admission: dialysis 22.9 vs 14.4%, p=0.002; transplant: 19.6 vs 9.3%, p=0.034. Managing ESRD patients on a stroke unit associated with lower risk of death at follow-up (HR 0.68, 95% CI 0.55-0.84).

Conclusions: Stroke incidence is high in ESRD. People on dialysis are functionally more dependent before stroke and less frequently receive optimal stroke care. Following stroke, death is more likely in ESRD patients. Acute stroke unit care may associate with lower mortality.