Division of Nephrology and Hypertension, University of California Irvine, Irvine, 333 City Blvd West, Suite 400, Orange, CA, USA.
J Stroke Cerebrovasc Dis. 2021 Sep;30(9):105679. doi: 10.1016/j.jstrokecerebrovasdis.2021.105679. Epub 2021 Feb 25.
Risk of both ischemic and hemorrhagic stroke is increased in the chronic kidney disease (CKD) population, particularly in end-stage kidney disease patients. Uremic factors that contribute to stroke risk include blood pressure variability, vascular calcification, build-up of vascular toxins, chronic inflammation, platelet dysfunction and increased brain microbleeds. This paper discusses the controversial evidence for stroke prevention strategies including blood pressure control, statins, antiplatelet agents, and anticoagulation in the CKD population. Only a few randomized clinical trials included patients with advanced CKD, thus evidence is derived mostly from observational cohorts and real-world data. Overall, targeting a lower systolic blood pressure below 120 mmHg and statin prescription do not appear to decrease stroke risk in CKD. Antiplatelet agents have not shown a clear benefit for secondary stroke prevention, but aspirin may reduce incident stroke in hypertensive CKD stage 3B-5 patients. Observational data suggests that the factor Xa inhibitor apixaban has a favorable profile over warfarin in dialysis patients with atrial fibrillation; apixaban being associated with lower stroke risk and fewer major bleeding events.
慢性肾脏病 (CKD) 患者的缺血性卒中和出血性卒中风险均增加，尤其是终末期肾病患者。导致卒中风险的尿毒症因素包括血压变异性、血管钙化、血管毒素积聚、慢性炎症、血小板功能障碍和脑微出血增加。本文讨论了针对 CKD 患者的卒中预防策略（包括血压控制、他汀类药物、抗血小板药物和抗凝）的争议性证据。只有少数随机临床试验纳入了晚期 CKD 患者，因此证据主要来自观察性队列和真实世界数据。总体而言，将收缩压目标值控制在 120mmHg 以下和开具他汀类药物似乎并不能降低 CKD 患者的卒中风险。抗血小板药物对二级卒中预防没有明显益处，但阿司匹林可能会降低高血压 CKD3B-5 期患者的卒中发生率。观察性数据表明，在伴有心房颤动的透析患者中，因子 Xa 抑制剂阿哌沙班的疗效优于华法林；阿哌沙班与较低的卒中风险和较少的大出血事件相关。
