Risks and benefits of antiplatelet therapy in uremic patients

Intravenous tissue plasminogen activator for acute ischemic stroke in patients with renal dysfunction

OBJECTIVE

This study used the Taiwan Stroke Registry data to evaluate the efficacy and safety of intravenous tissue plasminogen activator (tPA) in treating acute ischemic stroke in patients with renal dysfunction.

DESIGN

We identified 3525 ischemic stroke patients and classified them into two groups according to the estimated glomerular filtration rate (eGFR) at the emergency department: ≥60, and <60 ml/min/1.73 m2 or on dialysis and by the propensity score from August 2006 to May 2015. The odds ratio of poor functional outcome (modified Rankin Scale ≥2) was calculated for patients with tPA treatment (N = 705), compared to those without tPA treatment (N = 2820), by eGFR levels, at 1, 3 and 6 months after ischemic stroke. We also evaluated the risks of intracerebral hemorrhage, upper gastrointestinal bleeding, mortality, between the two groups by eGFR levels.

RESULTS

Among patients with eGFR levels of <60 ml/min/1.73 m2, tPA therapy reduced the odds ratio of poor functional outcome to 0.60 (95% confidence interval = 0.42-0.87) at 6 months after ischemic stroke. The tPA therapy was not associated with increased overall risk of upper gastrointestinal bleeding, but with increased risk of intracerebral hemorrhage. The low eGFR was not a significant risk factor of intracerebral hemorrhage among ischemic stroke patients receiving tPA treatment.

CONCLUSIONS

tPA for acute ischemic stroke could improve functional outcomes without increasing the risks of upper gastrointestinal bleeding for patients with or without renal dysfunction. The low eGFR was not a significant risk factor for intracerebral hemorrhage among patients receiving tPA treatment.

Is there a cardiovascular protective effect of aspirin in chronic kidney disease patients? A systematic review and meta-analysis

PURPOSE

To perform a systematic review and meta-analysis to evaluate the cardiovascular prevention effect of aspirin among patients with chronic kidney disease (CKD).

METHODS

A comprehensive literature search was conducted in Embase, PubMed, and Cochrane library (up to March 2019) without language limitations. Randomized control trials (RCT) and observational studies that met the inclusion and exclusion criteria were included. Two reviewers independently extracted data, and evaluated study quality using modified Jadad score for RCTs and Newcastle-Ottawa Scale for observational study. A meta-analysis was conducted in the Stata 15.0 software using the DerSimonian and Laird random-effects model.

RESULTS

1768 references were identified from literature searching. Four RCTs and four cohort studies that reported the cardiovascular prevention outcome of aspirin in CKD patients (38,341 participants) were included in this review. The pooled data revealed that aspirin had no significant prevention effect on cardiovascular events among CKD patients (RR = 0.96, 95% CI, 0.59-1.13). There was also no significant reduction in cardiovascular mortality and all-cause mortality. Although we found no significant increased risk in major bleeding events, there was a statistically significant increased risk of minor bleeding events (RR = 2.57, 95% CI, 1.60-4.13) and renal events (RR = 1.30, 95% CI, 1.02-1.65) for aspirin use.

CONCLUSION

Our review indicated that aspirin use in CKD patients had no prevention effect on cardiovascular events and no statistically significant reduction in risk of cardiovascular or all-cause mortality, with a significant increased risk of minor bleeding and renal events.

P2Y12 inhibitors in acute coronary syndrome patients with renal dysfunction: an analysis from the RENAMI and BleeMACS projects

Aims

The aim of the present study was to establish the safety and efficacy profile of prasugrel and ticagrelor in real-life acute coronary syndrome (ACS) patients with renal dysfunction.

Methods and results

All consecutive patients from RENAMI (REgistry of New Antiplatelets in patients with Myocardial Infarction) and BLEEMACS (Bleeding complications in a Multicenter registry of patients discharged with diagnosis of Acute Coronary Syndrome) registries were stratified according to estimated glomerular filtration rate (eGFR) lower or greater than 60 mL/min/1.73 m2. Death and myocardial infarction (MI) were the primary efficacy endpoints. Major bleedings (MBs), defined as Bleeding Academic Research Consortium bleeding types 3 to 5, constituted the safety endpoint. A total of 19 255 patients were enrolled. Mean age was 63 ± 12; 14 892 (77.3%) were males. A total of 2490 (12.9%) patients had chronic kidney disease (CKD), defined as eGFR &lt;60 mL/min/1.73 m2. Mean follow-up was 13 ± 5 months. Mortality was significantly higher in CKD patients (9.4% vs. 2.6%, P &lt; 0.0001), as well as the incidence of reinfarction (5.8% vs. 2.9%, P &lt; 0.0001) and MB (5.7% vs. 3%, P &lt; 0.0001). At Cox multivariable analysis, potent P2Y12 inhibitors significantly reduced the mortality rate [hazard ratio (HR) 0.82, 95% confidence interval (CI) 0.54–0.96; P = 0.006] and the risk of reinfarction (HR 0.53, 95% CI 0.30–0.95; P = 0.033) in CKD patients as compared to clopidogrel. The reduction of risk of reinfarction was confirmed in patients with preserved renal function. Potent P2Y12 inhibitors did not increase the risk of MB in CKD patients (HR 1.00, 95% CI 0.59–1.68; P = 0.985).

Conclusion

In ACS patients with CKD, prasugrel and ticagrelor are associated with lower risk of death and recurrent MI without increasing the risk of MB.

A case of cerebral infarction during a hemodialysis procedure successfully treated with recombinant tissue plasminogen activator

Thrombolytic therapy is an effective treatment for acute ischemic stroke and provides benefits and improvements that lead to better neurological outcomes. However, thrombolytic therapy with recombinant tissue plasminogen activator (r-tPA) in hemodialysis (HD) patients is limited because HD patients have a higher risk of bleeding. We report a case of a 75-year-old HD patient who presented with sudden aphasia during HD treatment. She was brought to the hospital for treatment for infarction. Following thrombolytic therapy, we achieved re-opening without complications. To our knowledge, no report has been published describing the patients who had a stroke during a maintenance HD session and were treated with r-tPA successfully. Although the number of HD patients treated with r-tPA is small and requires further investigation, thrombolytic therapy can be an alternative option. After weighing the risks and benefits and assessing each patient carefully, the use of r-tPA should be considered, even in HD patients.

Thrombolysis in chinese ischemic stroke patients with renal dysfunction

BACKGROUND

Current data concerning the relationship between renal function and clinical outcome among stroke patients treated with intravenous thrombolytic therapy are conflicting. Our aim is to analyze whether the clinical outcome of Chinese ischemic stroke patients treated with thrombolytic therapy is affected by the presence of renal dysfunction.

METHODS

Chinese patients who received intravenous thrombolytic therapy for acute ischemic stroke were recruited. Renal dysfunction was defined as an estimated glomerular filtration rate (eGFR) <90 ml/min/1.73 m(2). The primary outcome was independent function (modified Rankin Scale, mRS, 0-2) at 3 months, while secondary outcomes included early improvement of the National Institute of Health Stroke Scale (NIHSS) score of ≥4 points at 24 h, symptomatic intracerebral hemorrhage (ICH) within 36 h of treatment and 30-day mortality.

RESULTS

A total of 199 patients were recruited, of whom 51.3% had renal dysfunction. There were no significant differences in functional independence at 3 months, NIHSS improvement at 24 h post-thrombolysis and 30-day mortality between patients with or without renal dysfunction. Multivariate analysis showed that eGFR as a continuous variable was not an independent risk factor for symptomatic ICH.

CONCLUSION

Chinese ischemic stroke patients with renal dysfunction who received thrombolytic therapy had clinical outcomes similar to those without renal dysfunction.

Low-dose aspirin for prevention of cardiovascular disease in patients with chronic kidney disease

Background

Chronic kidney disease (CKD) is a major risk factor for the development of cardiovascular disease (CVD). Previous trials have investigated the effects of low-dose aspirin on CVD prevention in patients with diabetes; however, patients with CKD were not examined. The role of aspirin in diabetics is controversial, and the available literature is contradictory. Therefore, we studied whether low-dose aspirin would be beneficial for patients with CKD, a group that is at high risk for CVD.

Method

From a total of 25340 patients with CKD, 1884 recipients of low-dose aspirin (100 mg/day) were paired 1∶1 with non-recipients for analysis using propensity score matching. The primary endpoint was the development of atherosclerotic CVD, including coronary arterial disease, stroke, and peripheral arterial disease. Secondary endpoints included death from any cause, bleeding events, doubling of serum creatinine, and renal death.

Results

The incidence of a primary endpoint of any atherosclerotic CVD was significantly higher in the aspirin users than in the non-users (P<0.001). Secondary endpoints, including all-cause mortality and composite bleeding events, were not significantly different between the aspirin users and the non-users. However, the doubling of serum creatinine levels (P = 0.001) and renal death (P = 0.042) were significantly associated with the use of aspirin.

Conclusion

These results suggest that the use of low-dose aspirin in patients with CKD may have harmful consequences related to the development of CVD and renal progression.

Stroke and renal dysfunction: are we always conscious of this relationship?

Cerebrovascular disease may represent an important clinical presentation of atherosclerosis in chronic kidney disease (CKD), and atherosclerosis is frequently encountered in CKD. In fact, kidney disease is now considered a risk factor for development of cardiovascular disease. Although guidelines for primary prevention of stroke have been recently published, CKD is hardly mentioned. Based on a series of available studies, we analyzed the relationship between reduced renal function, end-stage renal disease (ESRD), and stroke. Reduced renal function and risk of stroke appear to be related to the highest risk of patients on dialysis treatment. Primary and secondary prevention of stroke should be encouraged in participants with renal dysfunction.

Safety and efficacy of antiplatelet and antithrombotic therapy in acute coronary syndrome patients with chronic kidney disease

Chronic kidney disease (CKD) is prevalent and affects an ever-increasing proportion of patients presenting with acute coronary syndrome (ACS). Patients with CKD have a higher risk of ACS and significantly higher mortality, and are also predisposed to increased bleeding complications. Antiplatelet and antithrombotic drugs form the bedrock of management of patients with ACS. Most randomized trials of these drugs exclude patients with CKD, and current guidelines for management of these patients are largely based on these trials. We aim to review the safety and efficacy of these drugs in patients with CKD presenting with ACS.