What is the treatment for a dialysis patient who has suffered a stroke?

Treatment for Stroke in Dialysis Patients

For dialysis patients who have suffered a stroke, treatment should include antiplatelet therapy (preferably aspirin), tight blood pressure control targeting systolic BP <120 mmHg, and appropriate management of dialysis parameters to minimize hemodynamic instability. 1

Acute Management

Thrombolysis for Ischemic Stroke

• It is reasonable to administer thrombolysis to CKD patients with acute ischemic stroke if otherwise indicated, even with evidence of microbleeds 1
• Limited data exists for dialysis patients, but expert opinion supports considering thrombolysis in otherwise eligible hemodialysis patients 2
• Caution: Dialysis patients may have higher risk of symptomatic intracranial hemorrhage and mortality with thrombolysis 1
• For hemodialysis patients, check PTT before thrombolysis and consider mechanical thrombectomy as an alternative 2

Dialysis Considerations in Acute Stroke

• Avoid aggressive ultrafiltration immediately after stroke to prevent hemodynamic instability
• Consider dialysate cooling (0.5°C below core body temperature) to improve hemodynamic stability 1
• Minimize systemic anticoagulation during dialysis sessions to reduce hemorrhage risk 1
• Maintain hemoglobin values between 10-12 g/dL (100-120 g/L) 1

Secondary Prevention

Antiplatelet Therapy

• Antiplatelet therapy is uniformly recommended for secondary stroke prevention in CKD patients 1
• Aspirin is the preferred agent for dialysis patients with prior ischemic stroke (HR 0.671, P<0.001) 3
• Aspirin has been shown to reduce stroke readmission (HR 0.715, P=0.002) without significantly increasing bleeding risk (HR 0.885, P=0.291) in dialysis patients 3

Blood Pressure Management

• Target systolic BP <120 mmHg according to KDIGO guidelines 1
• Use renin-angiotensin system (RAS) blockers as first-line antihypertensive agents 1
• For dialysis patients, careful attention to volume control is essential 1
• Monitor for post-dialytic drops in SBP; drops up to 30 mmHg may be beneficial, but greater decreases can increase mortality 1

Lipid Management

• For CKD patients who have had a stroke, statin therapy is recommended 1
• For dialysis patients specifically:
  • Continue statins if already taking them
  • Do not initiate statins unless LDL-C levels are very high (>3.8 mmol/L or 145 mg/dL) 1

Anticoagulation for Atrial Fibrillation

• For dialysis patients with atrial fibrillation, anticoagulation decisions should be made in consultation with a nephrologist 1
• Limited evidence exists for DOACs in dialysis patients; warfarin has been associated with vascular calcification 1
• The decision to anticoagulate should be individualized based on stroke and bleeding risks 1

Optimizing Dialysis Parameters

• Consider hemodiafiltration which has been associated with 61% risk reduction in stroke compared to conventional hemodialysis 1
• Avoid long interdialytic gaps which are associated with higher stroke event rates 1
• Consider more frequent hemodialysis to improve BP control and reduce left ventricular mass 1
• Maintain careful volume control and hemodynamic stability during dialysis sessions 1

Carotid Interventions

• Consider carotid revascularization in very high-risk dialysis patients with symptomatic carotid stenosis 1
• Routine carotid revascularization is not recommended for asymptomatic disease in dialysis patients 1
• The presence of an embolic pattern of silent cerebral infarcts in carotid territory may influence decision-making regarding revascularization 1

Additional Considerations

• For diabetic dialysis patients with eGFR >30 mL/min/1.73m², consider SGLT2 inhibitors 1
• Encourage lifestyle modifications including smoking cessation, weight management, and regular exercise 1
• Dual pathway blockade (antiplatelet plus low-dose anticoagulant) could be considered for secondary prevention, though evidence is limited 1

Dialysis patients have 5-30 times higher risk of stroke with up to 90% case fatality rates 4, making aggressive preventive strategies essential despite the limited evidence base. The treatment approach must balance the high risk of recurrent stroke against the increased bleeding risk in this population.