Herrington William, Haynes Richard, Staplin Natalie, Emberson Jonathan, Baigent Colin, Landray Martin
Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; Oxford Kidney Unit, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom.
Semin Dial. 2015 Jan-Feb;28(1):35-47. doi: 10.1111/sdi.12281. Epub 2014 Jul 7.
The risks of both ischemic and hemorrhagic stroke are particularly high in dialysis patients of any age and outcomes are poor. It is therefore important to identify strategies that safely minimize stroke risk in this population. Observational studies have been unable to clarify the relative importance of traditional stroke risk factors such as blood pressure and cholesterol in those on dialysis, and are affected by biases that usually make them an inappropriate source of data on which to base therapeutic decisions. Well-conducted randomized trials are not susceptible to such biases and can reliably investigate the causal nature of the association between a potential risk factor and the outcome of interest. However, dialysis patients have been under-represented in the cardiovascular trials which have proven net benefit of commonly used preventative treatments (e.g., antihypertensive treatments, low-dose aspirin, carotid revascularization, and thromboprophylaxis for atrial fibrillation), and there remains uncertainty about safety and efficacy of many of these treatments in this high-risk population. Moreover, the efficacy of renal-specific therapies that might reduce cardiovascular risk, such as modulators of mineral and bone disorder, online hemodiafiltration, and daily (nocturnal) hemodialysis, have not been tested in adequately powered trials. Recent trials have also demonstrated how widespread current practices could be causing stroke. Therefore, it is important that reliable information on the prevention and treatment of stroke (and other cardiovascular disease) in dialysis patients is generated by performing large-scale randomized trials of many current and future treatments.
任何年龄段的透析患者发生缺血性和出血性卒中的风险都特别高，且预后较差。因此，确定能安全降低该人群卒中风险的策略很重要。观察性研究未能阐明传统卒中危险因素（如血压和胆固醇）在透析患者中的相对重要性，并且受偏倚影响，这通常使其不适用于作为治疗决策依据的数据来源。开展良好的随机试验不易受此类偏倚影响，能够可靠地研究潜在危险因素与感兴趣结局之间关联的因果性质。然而，在已证明常用预防性治疗（如抗高血压治疗、低剂量阿司匹林、颈动脉血运重建以及心房颤动的血栓预防）有净获益的心血管试验中，透析患者的代表性不足，而且这些治疗中许多在这一高危人群中的安全性和有效性仍存在不确定性。此外，可能降低心血管风险的肾脏特异性疗法，如矿物质和骨代谢紊乱调节剂、在线血液透析滤过以及每日（夜间）血液透析的疗效，尚未在有足够效力的试验中得到检验。近期试验还表明，当前的普遍做法可能在多大程度上导致卒中。因此，通过对许多当前和未来治疗方法进行大规模随机试验来生成关于透析患者卒中（及其他心血管疾病）预防和治疗的可靠信息很重要。
