Impact and interaction of low estimated GFR and B vitamin therapy on prognosis among ischemic stroke patients: the Vitamin Intervention for Stroke Prevention (VISP) trial

Prevention and treatment of stroke in patients with chronic kidney disease: an overview of evidence and current guidelines

Chronic kidney disease is strongly associated with an increased risk of stroke, small vessel disease, and vascular dementia. Common vascular factors for stroke, such as hypertension, diabetes, and atrial fibrillation, are more prevalent in patients with chronic kidney disease, accounting for this association. However, factors unique to these patients, such as uremia, oxidative stress, and mineral and bone abnormalities, as well as dialysis-related factors are also believed to contribute to risk. Despite improvements in stroke treatment and survival in the general population, the rate of improvement in patients with chronic kidney disease, especially those who are dialysis dependent, has lagged behind. There is a lack of or conflicting evidence that those with renal disease, particularly when advanced or older, consistently derive benefit from currently available preventive and therapeutic interventions for stroke in the general population. In this review, we explore the complexities and challenges of these interventions in the population with renal disease.

Serum iron levels are an independent predictor of in-hospital mortality of critically ill patients: a retrospective, single-institution study

Objective

This study aimed to examine the relationship between serum iron levels and in-hospital mortality in critically ill patients.

Methods

We retrospectively studied 250 critically ill patients who received treatment at the intensive care unit between June 2015 and May 2017. Blood chemistry and hepatic and renal function were measured. Kaplan–Meier survival curves were plotted according to serum iron levels. Correlations between serum iron levels and other variables were analyzed.

Results

A total of 165 (66.0%) patients had abnormally low serum iron levels (<10.6 μmol/L). Patients who died during hospitalization had markedly higher Acute Physiology and Chronic Health Evaluation II scores and significantly lower serum iron levels compared with those who survived. Cumulative survival was significantly lower in patients with low serum iron levels than in those with normal serum iron levels in subgroup analysis of older patients (n = 192). Multivariate regression analysis showed that, after adjusting for relevant factors, low serum iron levels remained an independent risk for in-hospital mortality (odds ratio 2.014; 95% confidence interval 1.089, 3.725).

Conclusions

Low serum iron levels are present in a significant proportion of critically ill patients and are associated with higher in-hospital mortality, particularly in older patients.

Association between estimated glomerular filtration rate and clinical outcomes in patients with acute ischaemic stroke: results from China National Stroke Registry

BACKGROUND

the impact of estimated glomerular filtration rate (eGFR) on stroke clinical outcomes remains controversial. We examined the association between eGFR and all-cause mortality, recurrent stroke, and stroke disability in patients with acute ischaemic stroke.

METHODS

we analysed 8865 patients with acute ischaemic stroke in the China National Stroke Registry (CNSR) between September 2007 and August 2008. Multivariate logistic regression analysis was used to evaluate the association between eGFR and 1-year all-cause mortality, recurrent stroke, and stroke disability. Low eGFR was defined as <45 ml/min/1.73 m(2).

RESULTS

of 8865 acute ischaemic stroke patients included in the analysis, eGFR of <45 ml/min/1.73 m(2) occurred in 394 (4.4%), eGFR of 45-59 ml/min/1.73 m(2) in 675 (7.6%), eGFR of 60-89 ml/min/1.73 m(2) in 3533 (39.9%), and eGFR of ≥90 ml/min/1.73 m(2) in 4263 (48.1%) at baseline. Patients with reduced renal function were more likely to die, experience recurrent stroke or have stroke disability than patients with preserved renal function. After adjusting for both demographic and clinical risk factors, an eGFR of <45 ml/min/1.73 m(2) was independently associated with 1-year all-cause mortality (OR: 2.65; 95% CI: 1.95-3.59) and recurrent stroke (OR: 1.97; 95% CI: 1.51-2.56) but not for stroke disability defined as modified Rankin Score of 2-6 (OR: 1.26; 95% CI: 0.95-1.67). These results were consistent in stratified analyses by age, diabetes or hypertension.

CONCLUSIONS

a low eGFR was associated with increased risks of all-cause mortality and recurrent stroke independent of the traditional vascular risk factors in Chinese stroke patients.

Patterns of care quality and prognosis among hospitalized ischemic stroke patients with chronic kidney disease

Background

Relatively little is known about the quality of care and outcomes for hospitalized ischemic stroke patients with chronic kidney disease (CKD). We examined quality of care and in‐hospital prognoses among patients with CKD in the Get With The Guidelines–Stroke (GWTG‐Stroke) program

Methods and Results

We analyzed 679 827 patients hospitalized with ischemic stroke from 1564 US centers participating in the GWTG‐Stroke program between January 2009 and December 2012. Use of 7 predefined ischemic stroke performance measures, composite “defect‐free” care compliance, and in‐hospital mortality were examined based on glomerular filtration rate (GFR) categorized as a dichotomous (+CKD as <60) or rank‐ordered variable: normal (≥90), mild (≥60 to <90), moderate (≥30 to <60), severe (≥15 to <30), and kidney failure (<15 or dialysis). There were 236 662 (35%) ischemic stroke patients with CKD. Patients with severe renal dysfunction or failure were significantly less likely to receive guideline‐based therapies. Compared with patients with normal kidney function (≥90), those with CKD (adjusted OR 0.91 [95% CI: 0.89 to 0.92]), moderate dysfunction (adjusted OR 0.94 [95% CI: 0.92 to 0.97]), severe dysfunction (adjusted OR 0.80 [95% CI: 0.77 to 0.84]), or failure (adjusted OR 0.72 [95% CI: 0.68 to 0.0.76]), were less likely to receive 100% defect‐free care measure compliance. Inpatient mortality was higher for patients with CKD (adjusted odds ratio 1.44 [95% CI: 1.40 to 1.47]), and progressively rose with more severe renal dysfunction.

Conclusions

Despite higher in‐hospital mortality rates, ischemic stroke patients with CKD, especially those with greater severity of renal dysfunction, were less likely to receive important guideline‐recommended therapies.

Effects of low estimated glomerular filtration rate on outcomes after stroke: a hospital-based stroke registry in China

BACKGROUND AND PURPOSE

As uncertainty persists over the prognostic significance of low estimated glomerular filtration rate (eGFR) in acute stroke, the effects of low eGFR on death/disability amongst participants with acute stroke in China were determined.

METHODS

Nanjing First Hospital stroke registry was a prospective cohort study of stroke patients. Patients with acute stroke (brain infarction, intracerebral hemorrhage or subarachnoid hemorrhage) within 7 days of onset were recruited consecutively from 2004 to 2008. Baseline eGFR was estimated using the Chronic Kidney Disease Epidemiology Collaboration equation. Outcomes were death/disability, defined by scores 3-6 on the modified Rankin Scale at 90 days.

RESULTS

A total of 1909 participants were included in the present analyses. Of them, 112 (5.9%) had baseline moderate to severe decrease in eGFR (G3b-4) and increasing risk of higher National Institutes of Health Stroke Scale (NIHSS) scores. Low eGFR was associated with increasing risk of death/disability at 90 days [G3b-4, odds ratio 2.58 (95% confidence interval 1.71-3.91); G3a, 1.86 (1.35-2.56); G2, 1.21 (0.96-1.52); P trend <0.001). However, the association was not statistically significant after adjustment for demographic and clinical factors including NIHSS scores.

CONCLUSIONS

There were no appreciable effects of low eGFR on death/disability at 90 days independent of other prognostic factors in Chinese patients with acute stroke.