Risk of stroke in hypertensive diabetic chronic kidney disease patients after central venous catheter placement

Stroke is the leading cause of death in patients with kidney failure. Chronic kidney disease (CKD) is strongly associated with stroke with various purported mechanisms proposed and End-stage renal disease (ESRD) patients are in a condition where both kidneys are impaired and require kidney transplantation or dialysis, and unfortunately, the number of patients with ESRD has grown rapidly during the last several decades. Several conventional risk factors for atherosclerosis are more prevalent in patients with CKD and the risk of stroke is 5–30 times higher in patients with CKD. Especially, Diabetic kidney disease (DKD) is the leading cause of ESRD and a significant risk factor for progressive macro- and microvascular disease. The risk of hemorrhagic stroke (HS) has been reported to be higher than ischemic stroke (IS) in hemodialysis (HD) patients. Moreover, for doing HD, creating a connection point in the patient‘s body is necessary; this connection point is creating in a vascular access (VA) surgery and there are three usual methods for a VA: Arterivenous Fistula (AVF), Arterivenous Graft (AVG) and central venous catheter (CVC). In these three mentioned VA methods, if the status of patient be urgent, creating CVC is a common approach for providing patient to a fast HD and continuing his or her life, such that implantation of a CVC is one of the most common surgeries for VA as a requirement for HD. In United States (US), the prevalence of recognized CKD has steadily risen year after year across all stages of CKD. From 2016 to 2017, the proportion of recognized CKD patients increased from13.8% to 14.5%. Among those without a CKD diagnosis but with both diabetes mellitus and hypertension, 43.2% had urine albumin testing in 2017, and a large majority (80%) of HD patients started dialysis using an indwelling catheter. The standardized US rates for ESRD (ie, dialysis or transplantation) rank among the highest in the world. The prevalence of ESRD continues to rise and reached 746,557 cases in 2017 (vs 727,912 in 2016), representing a 2.6% increase since 2016, The published annual data report also highlights key findings regarding ESRD among children, adolescents, and young adults. From other hand, although there are various paths for inserting CVC, such as subclavian, jugular and femoral, but the important problem is that, there are some reports about high risk of stroke is both in CKD patients and far higher in patients with CVC implanted for HD! Given the risk of death after stroke and the problems it poses to the individual, others, and the community, it is important to evaluate the risk in patients with underlying conditions. Indeed, with greatly increased risk of stroke and poorer outcomes, in this vulnerable group of patients, it is important that preventive strategies be better applied to reduce stroke rates. Thereby, this article is a review of stroke in patients with DKD and approach to managing it.

In the present study, we analyzed totally data of 1566 patients, which included two datasets: at first, there are 1098 stroke patients from US and secondly, there are 468 Iranian HD patients, who have used CVC as a VA method for HD possibility. The first dataset is shared by the US researchers for completing their previous studies and second dataset gathered after designing a check list from the Hospital Information System (HIS), based on saved files of the under HD patients who accept by the study on their treatment data. The stroke populations were referred over two years and HD populations to US hospitals were referred over a five-year to Hasheminejad Kidney Hospital. For data analysis, we calculated correlation coefficients by SPSS software. Moreover, for targeting extract novel, useful and hidden patterns from the data, we executed data mining algorithms in both Rapid Miner Studio and SPSS tools. Indeed, with the help of data mining techniques, more details of association rules into the patient characteristics will be revealed. Therefore, we designed descriptive approaches of data mining, which were included: (a) Decision Tree Operator for data classification (by accuracy rate = 81.51%) which implemented in Rapid Miner Studio and (b) CHAID algorithm which executed in SPSS software (by accuracy rate of classification= 98.75%). These accuracy rates explain an acceptable result in their related decision trees which gives us the motivation to interpret them as a scientific idea and adapt to medical realities.

In the first data set, 891 patients had IS and 207 patients had HS; in these patients, where 388 patients had kidney problems and 64 patients had chronic kidney disease. Studies showed that there was a significant relationship between chronic kidney disease and ischemic stroke (Pearson correlation with p<0.001). The second data set consists 468 hemodialysis patients, including 324 females and 144 males, of which 368 patients had a permanent catheter and 100 had a non-cuffed catheter. By interpreting the exported decision tree, these results were evident: (a) the history of kidney diseases has an unmissable role in trouble patients to the stroke! This is because that the kidney variable was placed in the root of the extracted decision tree. (b) after history of kidney diseases, the second-high risk role in the case of stroke, was dedicated to history of heart diseases; (c) in both of recent results, the dominant type of stroke is related to IS. (d)

This study showed that the risk of stroke in patients who used catheters before venous arterial fistula was 84.21% and while there was no significant relationship between the age of dialysis patients and their stroke, but in addition to catheter implantation, they had a history of hypertension or diabetes were also at risk for stroke. Finally, we discuss a paradox with reference to what we presented at the WoCoVA 2020 Conference and suggest that for future research on the relationship between the various methods of VA - which are essential for hemodialysis and patient life - with stroke and investigate the increased risk of death.