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Bobot M, Suissa L, Hak JF, Burtey S, Guillet B, Hache G. Kidney disease and stroke: epidemiology and potential mechanisms of susceptibility. Nephrol Dial Transplant 2023; 38:1940-1951. [PMID: 36754366 DOI: 10.1093/ndt/gfad029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Indexed: 02/10/2023] Open
Abstract
Patients with chronic kidney disease (CKD) have an increased risk of both ischaemic and haemorrhagic stroke compared with the general population. Both acute and chronic kidney impairment are independently associated with poor outcome after the onset of a stroke, after adjustment for confounders. End-stage kidney disease (ESKD) is associated with a 7- and 9-fold increased incidence of both ischaemic and haemorrhagic strokes, respectively, poorer neurological outcome and a 3-fold higher mortality. Acute kidney injury (AKI) occurs in 12% of patients with stroke and is associated with a 4-fold increased mortality and unfavourable functional outcome. CKD patients seem to have less access to revascularisation techniques like thrombolysis and thrombectomy despite their poorer prognosis. Even if CKD patients could benefit from these specific treatments in acute ischaemic stroke, their prognosis remains poor. After thrombolysis, CKD is associated with a 40% increased risk of intracerebral haemorrhage (ICH), a 20% increase in mortality and poorer functional neurological outcomes. After thrombectomy, CKD is not associated with ICH but is still associated with increased mortality, and AKI with unfavourable outcome and mortality. The beneficial impact of gliflozins on the prevention of stroke is still uncertain. Non-traditional risk factors of stroke, like uraemic toxins, can lead to chronic cerebrovascular disease predisposing to stroke in CKD, notably through an increase in the blood-brain barrier permeability and impaired coagulation and thrombosis mechanisms. Preclinical and clinical studies are needed to specifically assess the impact of these non-traditional risk factors on stroke incidence and outcomes, aiming to optimize and identify potential therapeutic targets.
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Affiliation(s)
- Mickaël Bobot
- Centre de Néphrologie et Transplantation Rénale, Hôpital de la Conception, AP-HM, Marseille, France
- Aix-Marseille Université, INSERM 1263, INRAE 1260, C2VN, Marseille, France
- CERIMED, Aix Marseille Université, Marseille, France
| | - Laurent Suissa
- Aix-Marseille Université, INSERM 1263, INRAE 1260, C2VN, Marseille, France
- Unité Neurovasculaire/Stroke Center, Hôpital de la Timone, AP-HM, Marseille, France
| | - Jean-François Hak
- CERIMED, Aix Marseille Université, Marseille, France
- Service de Radiologie, Hôpital de la Timone, AP-HM, Marseille, France
| | - Stéphane Burtey
- Centre de Néphrologie et Transplantation Rénale, Hôpital de la Conception, AP-HM, Marseille, France
- Aix-Marseille Université, INSERM 1263, INRAE 1260, C2VN, Marseille, France
| | - Benjamin Guillet
- Aix-Marseille Université, INSERM 1263, INRAE 1260, C2VN, Marseille, France
- CERIMED, Aix Marseille Université, Marseille, France
- Service de Radiopharmacie, AP-HM, Marseille, France
| | - Guillaume Hache
- Aix-Marseille Université, INSERM 1263, INRAE 1260, C2VN, Marseille, France
- CERIMED, Aix Marseille Université, Marseille, France
- Pharmacie, Hôpital de la Timone, AP-HM, Marseille, France
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Egashira S, Koga M, Toyoda K. Intravenous Thrombolysis for Acute Ischemic Stroke in Patients with End-Stage Renal Disease on Hemodialysis: A Narrative Review. J Cardiovasc Dev Dis 2022; 9:jcdd9120446. [PMID: 36547443 PMCID: PMC9785222 DOI: 10.3390/jcdd9120446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/04/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Acute ischemic stroke (AIS) is a significant and devastating complication in patients with end-stage renal disease on hemodialysis (ESRD/HD). Since one-third of AIS in ESRD/HD patients occurs during or soon after dialysis, patients are more likely to present within the time window when intravenous thrombolysis (IVT) can be performed. IVT may improve prognosis in ESRD/HD patients with AIS. However, ESRD/HD patients have been excluded from large trials and may have been withheld from IVT due to concerns about bleeding complications. To date, there is no clear evidence and firm guidance on the safety and efficacy of IVT in ESRD/HD patients with AIS. This narrative review aimed to evaluate critical scientific data on the benefits and risks of IVT use in patients with ESRD/HD and AIS. MATERIALS AND METHODS We searched the electronic database of PubMed for studies evaluating the relationship between AIS, ESRD/HD, and IVT. Reference sections and additional publications were also searched manually. Studies on AIS in patients with ESRD/HD requiring maintenance dialysis that referred to IVT were included. RESULTS In total, 560 studies were found in the PubMed electronic database during the period covered, of which 10 met the selection criteria. IVT for AIS in ESRD/HD patients could improve neurological outcomes and be safely performed even with the possibility of hemorrhagic complications associated with hypertension. Despite the high complication and mortality rates in ESRD/HD patients with AIS after IVT, the association with IVT was unclear. CONCLUSIONS IVT for AIS in ESRD/HD patients may improve outcomes and should not be withheld based solely on ESRD/HD status.
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Affiliation(s)
| | - Masatoshi Koga
- Correspondence: ; Tel.: +81-6-6170-1070; Fax: +81-6-6170-1348
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Wang IK, Yen TH, Chen CH, Hsu SP, Sun Y, Lien LM, Chang WL, Lai TC, Chen PL, Chen CC, Huang PH, Lin CH, Su YC, Lin MC, Li CY, Sung FC, Hsu CY. Intravenous tissue plasminogen activator for acute ischemic stroke in patients with renal dysfunction. QJM 2022; 114:848-856. [PMID: 32770252 DOI: 10.1093/qjmed/hcaa237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/06/2020] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- I-K Wang
- From the Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
- Department of Internal Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Division of Nephrology, China Medical University Hospital, Taichung, Taiwan
| | - T-H Yen
- Division of Nephrology, Chang Gung Memorial Hospital, Taipei, Taiwan
- Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - C-H Chen
- Department of Neurology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Stroke Center, National Cheng Kung University Hospital, Tainan, Taiwan
| | - S-P Hsu
- Department of Neurology, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan
| | - Y Sun
- Neurology, En Chu Kong Hospital, New Taipei City, Taiwan
| | - L-M Lien
- Department of Neurology, Shin Kong Wu-Ho-Su Memorial Hospital, Taipei, Taiwan
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - W-L Chang
- Department of Neurology, Show Chwan Memorial Hospital, Changhua County, Taiwan
| | - T-C Lai
- Division of Neurology Department of Internal Medicine, Cheng Hsin General Hospital, Taipei, Taiwan
| | - P-L Chen
- Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Neurology, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - C-C Chen
- Department of Neurology, St Martin De Porres Hospital, Chiayi City, Taiwan
| | - P-H Huang
- Department of Neurology, Cathay General Hospital, Taipei, Taiwan
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - C-H Lin
- Section of Neurology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Y-C Su
- Management Office for Health Data
| | - M-C Lin
- Management Office for Health Data
| | - C-Y Li
- From the Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
- Department of Anesthesiology, China Medical University Hospital, Taichung, Taiwan
| | - F-C Sung
- Department of Health Services Administration, China Medical University College of Public Health, Taichung 404, Taiwan
- Department of Food Nutrition and Health Biotechnology, Asia University, Lioufeng Road, Wufeng, Taichung, Taiwan
| | - C Y Hsu
- From the Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
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Marini S, Georgakis MK, Anderson CD. Interactions Between Kidney Function and Cerebrovascular Disease: Vessel Pathology That Fires Together Wires Together. Front Neurol 2021; 12:785273. [PMID: 34899586 PMCID: PMC8652045 DOI: 10.3389/fneur.2021.785273] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 10/26/2021] [Indexed: 12/15/2022] Open
Abstract
The kidney and the brain, as high-flow end organs relying on autoregulatory mechanisms, have unique anatomic and physiological hemodynamic properties. Similarly, the two organs share a common pattern of microvascular dysfunction as a result of aging and exposure to vascular risk factors (e.g., hypertension, diabetes and smoking) and therefore progress in parallel into a systemic condition known as small vessel disease (SVD). Many epidemiological studies have shown that even mild renal dysfunction is robustly associated with acute and chronic forms of cerebrovascular disease. Beyond ischemic SVD, kidney impairment increases the risk of acute cerebrovascular events related to different underlying pathologies, notably large artery stroke and intracerebral hemorrhage. Other chronic cerebral manifestations of SVD are variably associated with kidney disease. Observational data have suggested the hypothesis that kidney function influences cerebrovascular disease independently and adjunctively to the effect of known vascular risk factors, which affect both renal and cerebral microvasculature. In addition to confirming this independent association, recent large-scale human genetic studies have contributed to disentangling potentially causal associations from shared genetic predisposition and resolving the uncertainty around the direction of causality between kidney and cerebrovascular disease. Accelerated atherosclerosis, impaired cerebral autoregulation, remodeling of the cerebral vasculature, chronic inflammation and endothelial dysfunction can be proposed to explain the additive mechanisms through which renal dysfunction leads to cerebral SVD and other cerebrovascular events. Genetic epidemiology also can help identify new pathological pathways which wire kidney dysfunction and cerebral vascular pathology together. The need for identifying additional pathological mechanisms underlying kidney and cerebrovascular disease is attested to by the limited effect of current therapeutic options in preventing cerebrovascular disease in patients with kidney impairment.
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Affiliation(s)
- Sandro Marini
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, United States
| | - Marios K Georgakis
- Institute for Stroke and Dementia Research, University Hospital of LMU Munich, Munich, Germany.,McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, United States.,Program in Medical and Population Genetics, Broad Institute, Cambridge, MA, United States
| | - Christopher D Anderson
- McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, United States.,Program in Medical and Population Genetics, Broad Institute, Cambridge, MA, United States.,Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States
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5
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Zamberg I, Assouline-Reinmann M, Carrera E, Sood MM, Sozio SM, Martin PY, Mavrakanas TA. Epidemiology, thrombolytic management, and outcomes of acute stroke among patients with chronic kidney disease: a systematic review and meta-analysis. Nephrol Dial Transplant 2021; 37:1289-1301. [PMID: 34100934 DOI: 10.1093/ndt/gfab197] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The relative frequency of ischemic versus hemorrhagic stroke among patients with chronic kidney disease (CKD) has not been clearly described. Moreover, no recent meta-analysis has investigated the outcomes of patients with CKD treated with thrombolysis for acute ischemic stroke. We conducted a systematic review and meta-analysis to estimate the proportion of stroke subtypes and the outcomes of thrombolysis in CKD. METHODS A PubMed, EMBASE and Cochrane literature research was conducted. The primary outcome was the proportion and incidence of ischemic versus hemorrhagic strokes among patients with CKD. In addition, we assessed the impact of CKD on disability, mortality, and bleeding among patients with acute ischemic stroke treated with thrombolysis. The pooled proportion and the risk ratio (RR) were estimated using a random-effects model. RESULTS Thirty-nine observational studies were included: 22 on the epidemiology of stroke types and 17 on the outcomes of thrombolysis in this population. In the main analysis (> 99,281 patients), ischemic stroke was more frequent than hemorrhagic among patients with CKD (78.3%, 95% confidence interval 73.3%-82.5%). However, among patients with kidney failure, the proportion of ischemic stroke decreased and was closer to that of hemorrhagic stroke: 59.8% (95% confidence interval 49.4%-69.4%). CKD was associated with worse clinical outcomes in patients with acute ischemic stroke compared with patients with preserved kidney function. CONCLUSIONS The relative frequency of hemorrhagic stroke seems to increase as kidney function declines. Among patients with acute ischemic stroke treated with thrombolysis, presence of CKD is associated with higher disability, mortality, and bleeding, compared with patients with preserved kidney function.
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Affiliation(s)
- Ido Zamberg
- Division of Anesthesiology, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Marie Assouline-Reinmann
- Division of Cardiology, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Emmanuel Carrera
- Division of Neurology, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
| | - Manish M Sood
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
| | - Stephen M Sozio
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Pierre-Yves Martin
- Division of Nephrology, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Thomas A Mavrakanas
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
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Malhotra K, Katsanos AH, Goyal N, Tayal A, Gensicke H, Mitsias PD, De Marchis GM, Berge E, Alexandrov AW, Alexandrov AV, Tsivgoulis G. Intravenous thrombolysis in patients with chronic kidney disease: A systematic review and meta-analysis. Neurology 2020; 95:e121-e130. [PMID: 32554767 DOI: 10.1212/wnl.0000000000009756] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 12/12/2019] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE To determine the association of chronic kidney disease (CKD) with the safety and efficacy of IV thrombolysis (IVT) among patients with acute ischemic stroke (AIS). METHODS A systematic review and pairwise meta-analysis of studies involving patients with CKD undergoing IVT for AIS were conducted to evaluate the following outcomes: symptomatic intracranial hemorrhage (sICH), asymptomatic and any intracranial hemorrhage (ICH), in-hospital and 3-month mortality, 3-month favorable functional outcome (FFO; modified Rankin Scale [mRS] score 0-1), and 3-month functional independence (FI, mRS score 0-2). CKD was defined with estimated glomerular filtration rate (eGFR) ranging from mild (eGFR 60-89 mL/min) to moderate (eGFR 30-59 mL/min) to severe (eGFR 15-29 mL/min). RESULTS We identified 20 studies comprising 60,486 patients with AIS treated with IVT. In unadjusted analyses, CKD was associated with sICH according to the National Institute of Neurological Disorders and Stroke (NINDS) (7 studies; odds ratio [OR] 1.41, 95% confidence interval [CI] 1.19-1.67) and European Cooperative Acute Stroke Study (ECASS) II (9 studies; OR 1.37, 95% CI 1.01-1.85) definitions, any ICH (8 studies; OR 1.42, 95% CI 1.18-1.70), 3-month mortality (9 studies; OR 2.20, 95% CI 1.72-2.81), 3-month FFO (8 studies; OR 0.58, 95% CI 0.47-0.72), and 3-month FI (8 studies; OR 0.57, 95% CI 0.46-0.71). In adjusted analyses, CKD was associated with sICH according to NINDS (4 studies; ORadj 1.34, 95% CI 1.01-1.79) and ECASS II (3 studies; ORadj 2.08, 95% CI 1.27-3.43) definitions, any ICH (6 studies; ORadj 1.41, 95% CI 1.01-1.97), in-hospital mortality (2 studies; ORadj 1.19, 95% CI 1.09-1.30), and 3-month FFO (6 studies; ORadj 0.80, 95% CI 0.70-0.92). CONCLUSIONS After adjustment for confounders in this pairwise meta-analysis, moderate to severe CKD is associated with increased risks of ICH and worse functional outcomes among patients with AIS treated with IVT.
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Affiliation(s)
- Konark Malhotra
- From the Department of Neurology (K.M., A.T.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K., A.W.A., A.V.A.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology and Stroke Center (H.G., G.M.D.M.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology (P.D.M.), School of Medicine, University of Crete, Greece; Department of Cardiology (E.B.), Oslo University Hospital, Norway; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece.
| | - Aristeidis H Katsanos
- From the Department of Neurology (K.M., A.T.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K., A.W.A., A.V.A.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology and Stroke Center (H.G., G.M.D.M.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology (P.D.M.), School of Medicine, University of Crete, Greece; Department of Cardiology (E.B.), Oslo University Hospital, Norway; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
| | - Nitin Goyal
- From the Department of Neurology (K.M., A.T.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K., A.W.A., A.V.A.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology and Stroke Center (H.G., G.M.D.M.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology (P.D.M.), School of Medicine, University of Crete, Greece; Department of Cardiology (E.B.), Oslo University Hospital, Norway; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
| | - Ashis Tayal
- From the Department of Neurology (K.M., A.T.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K., A.W.A., A.V.A.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology and Stroke Center (H.G., G.M.D.M.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology (P.D.M.), School of Medicine, University of Crete, Greece; Department of Cardiology (E.B.), Oslo University Hospital, Norway; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
| | - Henrik Gensicke
- From the Department of Neurology (K.M., A.T.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K., A.W.A., A.V.A.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology and Stroke Center (H.G., G.M.D.M.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology (P.D.M.), School of Medicine, University of Crete, Greece; Department of Cardiology (E.B.), Oslo University Hospital, Norway; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
| | - Panayiotis D Mitsias
- From the Department of Neurology (K.M., A.T.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K., A.W.A., A.V.A.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology and Stroke Center (H.G., G.M.D.M.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology (P.D.M.), School of Medicine, University of Crete, Greece; Department of Cardiology (E.B.), Oslo University Hospital, Norway; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
| | - Gian Marco De Marchis
- From the Department of Neurology (K.M., A.T.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K., A.W.A., A.V.A.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology and Stroke Center (H.G., G.M.D.M.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology (P.D.M.), School of Medicine, University of Crete, Greece; Department of Cardiology (E.B.), Oslo University Hospital, Norway; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
| | - Eivind Berge
- From the Department of Neurology (K.M., A.T.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K., A.W.A., A.V.A.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology and Stroke Center (H.G., G.M.D.M.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology (P.D.M.), School of Medicine, University of Crete, Greece; Department of Cardiology (E.B.), Oslo University Hospital, Norway; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
| | - Anne W Alexandrov
- From the Department of Neurology (K.M., A.T.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K., A.W.A., A.V.A.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology and Stroke Center (H.G., G.M.D.M.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology (P.D.M.), School of Medicine, University of Crete, Greece; Department of Cardiology (E.B.), Oslo University Hospital, Norway; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
| | - Andrei V Alexandrov
- From the Department of Neurology (K.M., A.T.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K., A.W.A., A.V.A.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology and Stroke Center (H.G., G.M.D.M.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology (P.D.M.), School of Medicine, University of Crete, Greece; Department of Cardiology (E.B.), Oslo University Hospital, Norway; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
| | - Georgios Tsivgoulis
- From the Department of Neurology (K.M., A.T.), Allegheny Health Network, Pittsburgh, PA; Department of Neurology (A.H.K., A.W.A., A.V.A.), University of Ioannina School of Medicine, Greece; Department of Neurology (N.G., G.T.), University of Tennessee Health Science Center, Memphis; Department of Neurology and Stroke Center (H.G., G.M.D.M.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology (P.D.M.), School of Medicine, University of Crete, Greece; Department of Cardiology (E.B.), Oslo University Hospital, Norway; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, "Attikon" University Hospital, Greece
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7
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Pan X, Zhou F, Shen R, Zhu Y, Arima H, Yang J, Zhou J. Influence of renal function on stroke outcome after mechanical thrombectomy: a prospective cohort study. BMC Neurol 2020; 20:134. [PMID: 32290835 PMCID: PMC7155325 DOI: 10.1186/s12883-020-01720-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 04/07/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND For acute ischemic stroke (AIS) patient receiving mechanical thrombectomy (MT), renal dysfunction was an independent risk factor of contrast-induced nephropathy which may affect clinical outcomes. However, the influence of renal function on stroke outcomes is still controversial. Thus, we aim to investigate the association between renal function and outcomes of AIS patients receiving MT. METHODS All consecutive stroke patients receiving MT were included in a prospective stroke registry in China from April 2015 to February 2019. Estimated glomerular filtration rate (eGFR) was measured on admission and categorized into G1 (≥ 90 ml/min/1.73 m2), G2 (60-89 ml/min/1.73 m2), G3a (45-59 ml/min/1.73 m2) and G3b-5 (≤44 ml/min/1.73 m2). Multivariable logistic regression analysis was performed to evaluate the association between eGFR and recanalization rate (thrombolysis in cerebral infarction scale 2b-3), symptomatic intracranial hemorrhage (sICH), death in hospital, death at 3 months and poor functional outcome (modified Rankin Scale 3-6 at 3 months). RESULTS A total of 373 patients were included in the study. Of them, 130 (34.9%) patients were in the eGFR group G1, 170 (45.6%) in G2, 46 (12.3%) in G3a, 27 (7.2%) in G3b-5. In multivariable logistic regression analysis, reduced eGFR was associated with increased risk of sICH (G3a, p = 0.016) and 3-month death (G3b-5, p = 0.025). However, no significant effects were observed between reduced eGFR and the risk of recanalization rate (p = 0.855), death in hospital (p = 0.970), and poor functional outcome (p = 0.644). CONCLUSIONS For AIS patients underwent MT, reduced eGFR was associated with increased risk of sICH and 3-month death. However, there were no appreciable effects of reduced eGFR on recanalization rate, death in hospital and 3-month functional outcome.
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Affiliation(s)
- Xiding Pan
- Department of Pharmacy, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Feng Zhou
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Rui Shen
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yubing Zhu
- Department of Pharmacy, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Hisatomi Arima
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Jie Yang
- Department of Neurology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, 610500, China
| | - Junshan Zhou
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China.
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8
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Zhu J, Shen X, Han C, Mei C, Zhou Y, Wang H, Kong Y, Jiang Y, Fang Q, Cai X. Renal Dysfunction Associated with Symptomatic Intracranial Hemorrhage after Intravenous Thrombolysis. J Stroke Cerebrovasc Dis 2019; 28:104363. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.104363] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 08/18/2019] [Indexed: 01/09/2023] Open
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9
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Chang TH, Chiu PF, Tsai CC, Chang CH, Wu CL, Kor CT, Li JR, Kuo CL, Huang CS, Chu CC, Lin CM, Chang CC. Favourable renal outcomes after intravenous thrombolytic therapy for acute ischemic stroke: Clinical implication of kidney-brain axis. Nephrology (Carlton) 2018; 24:896-903. [PMID: 30334303 DOI: 10.1111/nep.13516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2018] [Indexed: 11/28/2022]
Abstract
AIM Recombinant tissue plasminogen activator (rt-PA) administration is the most prevalent treatment for acute ischemic within golden time. However, the effects of rt-PA on the kidney function in such patients remain unknown. This study determined long-term renal outcomes in patients with acute ischemic stroke receiving systemic rt-PA. METHODS We enroled patients who were hospitalized for acute ischemic stroke from January 2001 to January 2017. We applied 1:2 propensity score matching to eliminate various confounding variables. We defined surrogate renal outcomes as declining of estimated glomerular filtration rate (eGFR) greater than 30% and 50%, and chronic kidney disease (CKD) with eGFR less than 60 mL/min. We then compared the 1-year eGFR with paired t-test in patients treated with or without rt-PA. RESULTS Overall, 343 of 1739 patients received rt-PA within golden time. After 1:2 propensity score matching, their baseline characteristics were grouped as treated with rt-PA (n = 235) or not (n = 394). rt-PA-treated patients exhibited slower renal progression, including the risk of eGFR declining greater than 30% (hazard ratio (HR), 0.72; P = 0.03), risk of declining eGFR greater than 50% (HR, 0.63; P = 0.046) and risk of CKD (HR, 0.61; P = 0.005). After 1-year cohort, the rt-PA group exhibited an improved renal outcome by the paired t-test (propensity match: ΔGFR = 9.1 (95% confidence interval: 6.3, 11.8), P < 0.001 in rt-PA group; ΔGFR = -1.1 (95% confidence interval: -2.9, 0.7), P = 0.23 in non-rt-PA group). In patients with eGFR less than 45 mL/min (n = 34), intracerebral haemorrhage was not reported. CONCLUSION Patients receiving rt-PA for acute ischemic stroke exhibit favourable renal outcomes, and no increased incidence of intracerebral haemorrhage occurs in rt-PA patients with advanced CKD.
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Affiliation(s)
- Teng-Hsiang Chang
- Nephrology Division, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Ping-Fang Chiu
- Nephrology Division, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Center of General Education, Tunghai University, Taichung, Taiwan.,Vascular & Genomic Research Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Chun-Chieh Tsai
- Nephrology Division, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Chin-Hua Chang
- Nephrology Division, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Chia-Lin Wu
- Nephrology Division, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Chew-Teng Kor
- Internal Medicine Research Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Jhao-Rong Li
- Internal Medicine Research Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Cheng-Ling Kuo
- Vascular & Genomic Research Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Ching-Shan Huang
- Vascular & Genomic Research Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Cheng-Chung Chu
- Department of computer science, Tunghai University, Taichung, Taiwan
| | - Chih-Ming Lin
- Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan.,Department of Social Work and Child Welfare, Providence University, Taichung, Taiwan.,Department of Medicinal Botanicals and Health Applications, Da-Yeh University, Changhua, Taiwan
| | - Chia-Chu Chang
- Nephrology Division, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Vascular & Genomic Research Center, Changhua Christian Hospital, Changhua, Taiwan.,Nephrology Division, Department of Internal Medicine, Kuang Tien General Hospital, Taichung, Taiwan.,Department of Nutrition, Hungkuang University, Taichung, Taiwan
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10
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Dynamic Changes in the Estimated Glomerular Filtration Rate Predict All-Cause Mortality After Intravenous Thrombolysis in Stroke Patients. Neurotox Res 2018; 35:441-450. [DOI: 10.1007/s12640-018-9970-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 09/22/2018] [Accepted: 10/10/2018] [Indexed: 01/05/2023]
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11
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Laible M, Möhlenbruch MA, Pfaff J, Jenetzky E, Ringleb PA, Bendszus M, Rizos T. Influence of Renal Function on Treatment Results after Stroke Thrombectomy. Cerebrovasc Dis 2017; 44:351-358. [DOI: 10.1159/000481147] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 08/29/2017] [Indexed: 01/11/2023] Open
Abstract
Background: Renal dysfunction (RD) may be associated with poor outcome in ischemic stroke patients treated with mechanical thrombectomy (MT), but data concerning this important and emerging comorbidity do not exist so far. Here, we investigated the influence of RD on postprocedural intracerebral hemorrhage (ICH), clinical outcome, and mortality in a large prospectively collected cohort of acute ischemic stroke patients treated with MT. Methods: Consecutive patients with anterior-circulation stroke treated with MT between October 2010 and January 2016 were included. RD was defined as glomerular filtration rate (GFR) <60 mL/min/1.73 m2. In a prospective database, clinical characteristics were recorded and brain images were analyzed for the presence of ICH after treatment in all patients. Clinical outcome was assessed by the modified Rankin Scale (mRS) after 3 months. To evaluate associations between clinical factors and outcomes uni- and multivariate regression analyses were conducted. Results: In total, 505 patients fulfilled all inclusion criteria (female: 49.7%, mean age: 71.0 years). RD at admission was present in 20.2%. RD patients were older and had cardiovascular risk factors more often. Multivariate regression analysis after adjustment for age, stroke severity, diabetes, hypertension, GFR, previous stroke, MT alone, or additional thrombolysis and recanalization results revealed that lower GFR was not independently associated with poor outcome (mRS 3-6; OR 1.13, 95% CI 0.99-1.28; p = 0.072) or ICH. However, lower GFR at admission was associated with a higher risk of mortality (OR 1.15, 95% CI 1.01-1.31; p = 0.038). Compared to admission, GFR values were higher at discharge (mean: 77.9 vs. 80.8 mL/min/1.73 m2; p = 0.046). Conclusions: We did not find evidence for an association of lower GFR with an increased risk of poor outcome and ICH, but lower GFR was a determinant of 90-day mortality after endovascular stroke treatment. Our findings encourage also performing MT in this relevant subgroup of acute ischemic stroke patients.
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Gadalean F, Simu M, Parv F, Vorovenci R, Tudor R, Schiller A, Timar R, Petrica L, Velciov S, Gluhovschi C, Bob F, Mihaescu A, Timar B, Spasovski G, Ivan V. The impact of acute kidney injury on in-hospital mortality in acute ischemic stroke patients undergoing intravenous thrombolysis. PLoS One 2017; 12:e0185589. [PMID: 29040276 PMCID: PMC5645137 DOI: 10.1371/journal.pone.0185589] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Accepted: 09/17/2017] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Acute kidney injury (AKI) increases the risk of death in acute ischemic stroke (AIS) patients. Intravenous thrombolytic therapy (iv. rt-PA) seems to be the most effective treatment for AIS patients. The effects of AKI on iv. rt-PA treated AIS cases is less studied. Our paper addresses this issue. METHODS 45 consecutive stroke patients treated with iv. rt-PA (median age = 64 years; 29 male) and 59 age and sex matched controls not eligible for iv. rt-PA have been enrolled in our study. Subjects were followed-up until hospital release or death (median follow up time = 12 days). RESULTS The prevalence of AKI did not differ between iv. rt-PA treated patients and controls (35.5% vs. 33.89%). In both groups, AKI was associated with increased in-hospital mortality: 50.0% vs. 3.4% p<0.0001 (in the rt-PA treated), and 45% vs. 30.7% (in controls). AKI iv. rt-PA treated patients had a significantly higher risk of in hospital mortality as compared to the no-AKI iv. rt-PA treated (HR = 15.2 (95%CI [1.87 to 124.24]; P = 0.011). In a Cox-multivariate model, the presence of AKI after iv. rt-PA remained a significant factor (HR = 8.354; p = 0.041) influencing the in-hospital mortality even after correction for other confounding factors. The independent predictors for AKI were: decreased eGFR baseline and elevated serum levels of uric acid at admission, (the model explained 60.2% of the AKI development). CONCLUSIONS The risk of AKI was increased in AIS patients. Thrombolysis itself did not increase the risk of AKI. In the iv. rt-PA patients, as compared to non-AKI, those which developed AKI had a higher rate of in-hospital mortality. The baseline eGFR and the serum uric acid at admission were independent predictors for AKI development in the iv. rt-PA treated AIS patients.
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Affiliation(s)
- Florica Gadalean
- Department of Nephrology, County Emergency Hospital Timisoara, Romania, ‘Victor Babes’ University of Medicine and Pharmacy, Timisoara, Romania
| | - Mihaela Simu
- Department of Neurology, County Emergency Hospital Timisoara, Romania, ‘Victor Babes’ University of Medicine and Pharmacy, Timisoara, Romania
| | - Florina Parv
- Department of Cardiology, County Emergency Hospital Timisoara, Romania, ‘Victor Babes’ University of Medicine and Pharmacy, Timisoara, Romania
- * E-mail:
| | - Ruxandra Vorovenci
- Department of Neurology, County Emergency Hospital Timisoara, Romania, ‘Victor Babes’ University of Medicine and Pharmacy, Timisoara, Romania
| | - Raluca Tudor
- Department of Neurology, County Emergency Hospital Timisoara, Romania, ‘Victor Babes’ University of Medicine and Pharmacy, Timisoara, Romania
| | - Adalbert Schiller
- Department of Nephrology, County Emergency Hospital Timisoara, Romania, ‘Victor Babes’ University of Medicine and Pharmacy, Timisoara, Romania
| | - Romulus Timar
- Department of Diabetes and Metabolic Diseases, County Emergency Hospital Timisoara, Romania, ‘Victor Babes’ University of Medicine and Pharmacy, Timisoara, Romania
| | - Ligia Petrica
- Department of Nephrology, County Emergency Hospital Timisoara, Romania, ‘Victor Babes’ University of Medicine and Pharmacy, Timisoara, Romania
| | - Silvia Velciov
- Department of Nephrology, County Emergency Hospital Timisoara, Romania, ‘Victor Babes’ University of Medicine and Pharmacy, Timisoara, Romania
| | - Cristina Gluhovschi
- Department of Nephrology, County Emergency Hospital Timisoara, Romania, ‘Victor Babes’ University of Medicine and Pharmacy, Timisoara, Romania
| | - Flaviu Bob
- Department of Nephrology, County Emergency Hospital Timisoara, Romania, ‘Victor Babes’ University of Medicine and Pharmacy, Timisoara, Romania
| | - Adelina Mihaescu
- Department of Nephrology, County Emergency Hospital Timisoara, Romania, ‘Victor Babes’ University of Medicine and Pharmacy, Timisoara, Romania
| | - Bogdan Timar
- Department of Bioinformatics, County Emergency Hospital Timisoara, Romania, ‘Victor Babes’ University of Medicine and Pharmacy, Timisoara, Romania
| | - Goce Spasovski
- Department of Nephrology, Medical Faculty, University of Skopje, Skopje, Macedonia
| | - Viviana Ivan
- Department of Cardiology, County Emergency Hospital Timisoara, Romania, ‘Victor Babes’ University of Medicine and Pharmacy, Timisoara, Romania
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Carr SJ, Wang X, Olavarria VV, Lavados PM, Rodriguez JA, Kim JS, Lee TH, Lindley RI, Pontes-Neto OM, Ricci S, Sato S, Sharma VK, Woodward M, Chalmers J, Anderson CS, Robinson TG. Influence of Renal Impairment on Outcome for Thrombolysis-Treated Acute Ischemic Stroke. Stroke 2017; 48:2605-2609. [DOI: 10.1161/strokeaha.117.017808] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 06/29/2017] [Accepted: 07/07/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Susan J. Carr
- From the John Walls Renal Unit, University Hospitals of Leicester NHS Trust, United Kingdom (S.J.C.); The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.W., M.W., J.C., C.S.A.); The George Institute for Global Health, University of Sydney, New South Wales, Australia (R.I.L.); Clinica Alemana de Santiago, Facultad de Medicina, Clinica Alemana, Universidad del Desarrollo, Santiago, Chile (V.V.O., P.M.L., J.A.R.); Departamento de Ciencias
| | - Xia Wang
- From the John Walls Renal Unit, University Hospitals of Leicester NHS Trust, United Kingdom (S.J.C.); The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.W., M.W., J.C., C.S.A.); The George Institute for Global Health, University of Sydney, New South Wales, Australia (R.I.L.); Clinica Alemana de Santiago, Facultad de Medicina, Clinica Alemana, Universidad del Desarrollo, Santiago, Chile (V.V.O., P.M.L., J.A.R.); Departamento de Ciencias
| | - Veronica V. Olavarria
- From the John Walls Renal Unit, University Hospitals of Leicester NHS Trust, United Kingdom (S.J.C.); The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.W., M.W., J.C., C.S.A.); The George Institute for Global Health, University of Sydney, New South Wales, Australia (R.I.L.); Clinica Alemana de Santiago, Facultad de Medicina, Clinica Alemana, Universidad del Desarrollo, Santiago, Chile (V.V.O., P.M.L., J.A.R.); Departamento de Ciencias
| | - Pablo M. Lavados
- From the John Walls Renal Unit, University Hospitals of Leicester NHS Trust, United Kingdom (S.J.C.); The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.W., M.W., J.C., C.S.A.); The George Institute for Global Health, University of Sydney, New South Wales, Australia (R.I.L.); Clinica Alemana de Santiago, Facultad de Medicina, Clinica Alemana, Universidad del Desarrollo, Santiago, Chile (V.V.O., P.M.L., J.A.R.); Departamento de Ciencias
| | - Jorge A. Rodriguez
- From the John Walls Renal Unit, University Hospitals of Leicester NHS Trust, United Kingdom (S.J.C.); The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.W., M.W., J.C., C.S.A.); The George Institute for Global Health, University of Sydney, New South Wales, Australia (R.I.L.); Clinica Alemana de Santiago, Facultad de Medicina, Clinica Alemana, Universidad del Desarrollo, Santiago, Chile (V.V.O., P.M.L., J.A.R.); Departamento de Ciencias
| | - Jong S. Kim
- From the John Walls Renal Unit, University Hospitals of Leicester NHS Trust, United Kingdom (S.J.C.); The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.W., M.W., J.C., C.S.A.); The George Institute for Global Health, University of Sydney, New South Wales, Australia (R.I.L.); Clinica Alemana de Santiago, Facultad de Medicina, Clinica Alemana, Universidad del Desarrollo, Santiago, Chile (V.V.O., P.M.L., J.A.R.); Departamento de Ciencias
| | - Tsong-Hai Lee
- From the John Walls Renal Unit, University Hospitals of Leicester NHS Trust, United Kingdom (S.J.C.); The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.W., M.W., J.C., C.S.A.); The George Institute for Global Health, University of Sydney, New South Wales, Australia (R.I.L.); Clinica Alemana de Santiago, Facultad de Medicina, Clinica Alemana, Universidad del Desarrollo, Santiago, Chile (V.V.O., P.M.L., J.A.R.); Departamento de Ciencias
| | - Richard I. Lindley
- From the John Walls Renal Unit, University Hospitals of Leicester NHS Trust, United Kingdom (S.J.C.); The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.W., M.W., J.C., C.S.A.); The George Institute for Global Health, University of Sydney, New South Wales, Australia (R.I.L.); Clinica Alemana de Santiago, Facultad de Medicina, Clinica Alemana, Universidad del Desarrollo, Santiago, Chile (V.V.O., P.M.L., J.A.R.); Departamento de Ciencias
| | - Octavio M. Pontes-Neto
- From the John Walls Renal Unit, University Hospitals of Leicester NHS Trust, United Kingdom (S.J.C.); The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.W., M.W., J.C., C.S.A.); The George Institute for Global Health, University of Sydney, New South Wales, Australia (R.I.L.); Clinica Alemana de Santiago, Facultad de Medicina, Clinica Alemana, Universidad del Desarrollo, Santiago, Chile (V.V.O., P.M.L., J.A.R.); Departamento de Ciencias
| | - Stefano Ricci
- From the John Walls Renal Unit, University Hospitals of Leicester NHS Trust, United Kingdom (S.J.C.); The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.W., M.W., J.C., C.S.A.); The George Institute for Global Health, University of Sydney, New South Wales, Australia (R.I.L.); Clinica Alemana de Santiago, Facultad de Medicina, Clinica Alemana, Universidad del Desarrollo, Santiago, Chile (V.V.O., P.M.L., J.A.R.); Departamento de Ciencias
| | - Shoichiro Sato
- From the John Walls Renal Unit, University Hospitals of Leicester NHS Trust, United Kingdom (S.J.C.); The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.W., M.W., J.C., C.S.A.); The George Institute for Global Health, University of Sydney, New South Wales, Australia (R.I.L.); Clinica Alemana de Santiago, Facultad de Medicina, Clinica Alemana, Universidad del Desarrollo, Santiago, Chile (V.V.O., P.M.L., J.A.R.); Departamento de Ciencias
| | - Vijay K. Sharma
- From the John Walls Renal Unit, University Hospitals of Leicester NHS Trust, United Kingdom (S.J.C.); The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.W., M.W., J.C., C.S.A.); The George Institute for Global Health, University of Sydney, New South Wales, Australia (R.I.L.); Clinica Alemana de Santiago, Facultad de Medicina, Clinica Alemana, Universidad del Desarrollo, Santiago, Chile (V.V.O., P.M.L., J.A.R.); Departamento de Ciencias
| | - Mark Woodward
- From the John Walls Renal Unit, University Hospitals of Leicester NHS Trust, United Kingdom (S.J.C.); The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.W., M.W., J.C., C.S.A.); The George Institute for Global Health, University of Sydney, New South Wales, Australia (R.I.L.); Clinica Alemana de Santiago, Facultad de Medicina, Clinica Alemana, Universidad del Desarrollo, Santiago, Chile (V.V.O., P.M.L., J.A.R.); Departamento de Ciencias
| | - John Chalmers
- From the John Walls Renal Unit, University Hospitals of Leicester NHS Trust, United Kingdom (S.J.C.); The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.W., M.W., J.C., C.S.A.); The George Institute for Global Health, University of Sydney, New South Wales, Australia (R.I.L.); Clinica Alemana de Santiago, Facultad de Medicina, Clinica Alemana, Universidad del Desarrollo, Santiago, Chile (V.V.O., P.M.L., J.A.R.); Departamento de Ciencias
| | - Craig S. Anderson
- From the John Walls Renal Unit, University Hospitals of Leicester NHS Trust, United Kingdom (S.J.C.); The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.W., M.W., J.C., C.S.A.); The George Institute for Global Health, University of Sydney, New South Wales, Australia (R.I.L.); Clinica Alemana de Santiago, Facultad de Medicina, Clinica Alemana, Universidad del Desarrollo, Santiago, Chile (V.V.O., P.M.L., J.A.R.); Departamento de Ciencias
| | - Thompson G. Robinson
- From the John Walls Renal Unit, University Hospitals of Leicester NHS Trust, United Kingdom (S.J.C.); The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.W., M.W., J.C., C.S.A.); The George Institute for Global Health, University of Sydney, New South Wales, Australia (R.I.L.); Clinica Alemana de Santiago, Facultad de Medicina, Clinica Alemana, Universidad del Desarrollo, Santiago, Chile (V.V.O., P.M.L., J.A.R.); Departamento de Ciencias
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Renal Dysfunction Is an Independent Risk Factor for Poor Outcome in Acute Ischemic Stroke Patients Treated with Intravenous Thrombolysis: A New Cutoff Value. Stroke Res Treat 2017; 2017:2371956. [PMID: 28127492 PMCID: PMC5239968 DOI: 10.1155/2017/2371956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Revised: 12/03/2016] [Accepted: 12/14/2016] [Indexed: 11/26/2022] Open
Abstract
Objective. This study was set to assess the effect of renal dysfunction on outcome of stroke patients treated with intravenous thrombolysis (IVT). Methods. This multicenter research involved 403 patients from January 2009 to March 2015. Patients were divided into two groups: (1) control group with GFR ≥ 45 mL/min/1.73 m2 and (2) low GFR group with GFR < 45 mL/min/1.73 m2. Outcome measurements were poor outcome (mRS 3–6) and mortality at 3 months and symptomatic intracerebral hemorrhage (SICH) within the first 24–36 hours. Univariate and multivariate regression analyses were performed, and odds ratios (ORs) were determined at 95% confidence intervals (CIs). Results. Univariate analyses determined that every decrease of GFR by 10 mL/min/1.73 m2 significantly increased the risk of poor outcome (OR 1.19, 95% CI 1.09–1.30, p < 0.001) and mortality (OR 1.18, 95% CI 1.06–1.32, p = 0.002). In multivariate regression, adjusted for all variables with p value < 0.1, low GFR (GFR < 45 versus GFR equal to or more than 45) was associated with poor outcome (OR adjusted 2.15, 95% CI 1.01–4.56, p = 0.045). Conclusion. In IVT for acute stroke, renal dysfunction with GFR < 45 mL/min/1.73 m2 before treatment determined increased odds for poor outcome compared to GFR of more than 45 mL/min/1.73 m2.
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Dad T, Weiner DE. Stroke and Chronic Kidney Disease: Epidemiology, Pathogenesis, and Management Across Kidney Disease Stages. Semin Nephrol 2016; 35:311-22. [PMID: 26355250 DOI: 10.1016/j.semnephrol.2015.06.003] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Cerebrovascular disease and stroke are very common at all stages of chronic kidney disease (CKD), likely representing both shared risk factors as well as synergy among risk factors. More subtle ischemic brain lesions may be particularly common in the CKD population, with subtle manifestations including cognitive impairment. For individuals with nondialysis CKD, the prevention, approach to, diagnosis, and management of stroke is similar to the general, non-CKD population. For individuals with end-stage renal disease, far less is known regarding strategies to prevent stroke. Stroke prophylaxis using warfarin in dialysis patients with atrial fibrillation in particular remains of uncertain benefit. End-stage renal disease patients can be managed aggressively in the setting of acute stroke. Outcomes after stroke at all stages of CKD are poor, and improving these outcomes should be the subject of future clinical trials.
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Affiliation(s)
- Taimur Dad
- Division of Nephrology, Tufts Medical Center, Boston, MA
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16
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Demaerschalk BM, Kleindorfer DO, Adeoye OM, Demchuk AM, Fugate JE, Grotta JC, Khalessi AA, Levy EI, Palesch YY, Prabhakaran S, Saposnik G, Saver JL, Smith EE. Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke. Stroke 2016; 47:581-641. [DOI: 10.1161/str.0000000000000086] [Citation(s) in RCA: 442] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose—
To critically review and evaluate the science behind individual eligibility criteria (indication/inclusion and contraindications/exclusion criteria) for intravenous recombinant tissue-type plasminogen activator (alteplase) treatment in acute ischemic stroke. This will allow us to better inform stroke providers of quantitative and qualitative risks associated with alteplase administration under selected commonly and uncommonly encountered clinical circumstances and to identify future research priorities concerning these eligibility criteria, which could potentially expand the safe and judicious use of alteplase and improve outcomes after stroke.
Methods—
Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and the American Heart Association’s Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge and, when appropriate, formulated recommendations using standard American Heart Association criteria. All members of the writing group had the opportunity to comment on and approved the final version of this document. The document underwent extensive American Heart Association internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.
Results—
After a review of the current literature, it was clearly evident that the levels of evidence supporting individual exclusion criteria for intravenous alteplase vary widely. Several exclusionary criteria have already undergone extensive scientific study such as the clear benefit of alteplase treatment in elderly stroke patients, those with severe stroke, those with diabetes mellitus and hyperglycemia, and those with minor early ischemic changes evident on computed tomography. Some exclusions such as recent intracranial surgery are likely based on common sense and sound judgment and are unlikely to ever be subjected to a randomized, clinical trial to evaluate safety. Most other contraindications or warnings range somewhere in between. However, the differential impact of each exclusion criterion varies not only with the evidence base behind it but also with the frequency of the exclusion within the stroke population, the probability of coexistence of multiple exclusion factors in a single patient, and the variation in practice among treating clinicians.
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Arnold J, Sims D, Ferro CJ. Modulation of stroke risk in chronic kidney disease. Clin Kidney J 2015; 9:29-38. [PMID: 26798458 PMCID: PMC4720212 DOI: 10.1093/ckj/sfv136] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 11/10/2015] [Indexed: 12/12/2022] Open
Abstract
Stroke is the second most common cause of death and the leading cause of neurological disability worldwide, with huge economic costs and tragic human consequences. Both chronic kidney disease (CKD) and end-stage kidney disease are associated with a significantly increased risk of stroke. However, to date this has generated far less interest compared with the better-recognized links between cardiac and renal disease. Common risk factors for stroke, such as hypertension, hypercholesterolaemia, smoking and atrial fibrillation, are shared with the general population but are more prevalent in renal patients. In addition, factors unique to these patients, such as disorders of mineral and bone metabolism, anaemia and its treatments as well as the process of dialysis itself, are all also postulated to further increase the risk of stroke. In the general population, advances in medical therapies mean that effective primary and secondary prevention therapies are available for many patients. The development of specialist stroke clinics and acute stroke units has also improved outcomes after a stroke. Emerging therapies such as thrombolysis and thrombectomy are showing increasingly beneficial results. However, patients with CKD and on dialysis have different risk profiles that must be taken into account when considering the potential benefits and risks of these treatments. Unfortunately, these patients are either not recruited or formally excluded from major clinical trials. There is still much work to be done to harness effective stroke treatments with an acceptable safety profile for patients with CKD and those on dialysis.
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Affiliation(s)
- Julia Arnold
- Department of Nephrology , Queen Elizabeth Hospital , Birmingham , UK
| | - Don Sims
- Department of Stroke Medicine , Queen Elizabeth Hospital , Birmingham , UK
| | - Charles J Ferro
- Department of Nephrology , Queen Elizabeth Hospital , Birmingham , UK
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Jung JM, Kim HJ, Ahn H, Ahn IM, Do Y, Choi JY, Seo WK, Oh K, Cho KH, Yu S. Chronic kidney disease and intravenous thrombolysis in acute stroke: A systematic review and meta-analysis. J Neurol Sci 2015; 358:345-50. [PMID: 26434615 DOI: 10.1016/j.jns.2015.09.353] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Revised: 08/20/2015] [Accepted: 09/15/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND The association between chronic kidney disease (CKD) and hemorrhagic complications or clinical outcomes in patients treated with intravenous (IV) thrombolytic agents is controversial. METHODS We searched multiple databases for studies on the association between CKD and symptomatic intracerebral hemorrhage (ICH) and/or clinical outcomes in acute stroke patients treated with IV tissue plasminogen activator (tPA). Observational studies that evaluated the association between CKD and outcomes after adjusting for other confounding factors were eligible. We assessed study quality and performed a meta-analysis. The main outcome was symptomatic ICH. The secondary outcomes were poor functional status at 3 months using the modified Rankin Scale, mortality at 3 months, and any ICH. RESULTS Seven studies were selected based on our eligibility criteria. Of 7168 patients treated with IV tPA, 2001 (27.9%) had CKD. Patients with CKD had a higher risk of symptomatic ICH and mortality [pooled odds ratio (OR) 1.56, 95% confidence interval (CI) 1.05-2.33 and pooled OR 1.70, 95% CI 1.03-2.81, respectively]. Patients with CKD were likely to have an increased risk of poor outcome at 3 months. There was no significant association between CKD and any ICH. CONCLUSIONS Chronic kidney disease may significantly affect symptomatic hemorrhagic complications and poor clinical outcomes following administration of IV tPA.
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Affiliation(s)
- Jin-Man Jung
- Department of Neurology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Republic of Korea
| | - Hyun Jung Kim
- Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Hyeongsik Ahn
- Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Il Min Ahn
- Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Republic of Korea; Department of Literary Arts, Brown University, RI, USA
| | - Youngrok Do
- Department of Neurology, Daegu Catholic Hospital, Dae-Gu Catholic University College of Medicine, Dae-Gu, Republic of Korea
| | - Jeong-Yoon Choi
- Department of Neurology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Republic of Korea
| | - Woo-Keun Seo
- Department of Neurology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Kyungmi Oh
- Department of Neurology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Kyung-Hee Cho
- Department of Neurology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Sungwook Yu
- Department of Neurology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea.
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Fabbian F. Impact of Glomerular Filtration Rate on Intravenous Thrombolytic Therapy in Acute Ischemic Stroke: A Retrospective Study from a Single Italian Center. ACTA ACUST UNITED AC 2015. [DOI: 10.17352/acn.000001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Lo WT, Cheung CY, Li CK, Chau KF, Fong WC. Thrombolysis in chinese ischemic stroke patients with renal dysfunction. INTERVENTIONAL NEUROLOGY 2015; 3:101-6. [PMID: 26019713 DOI: 10.1159/000375466] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Wai Ting Lo
- Department of Medicine, Queen Elizabeth Hospital, Hong Kong, SAR, China
| | - Chi Yuen Cheung
- Department of Medicine, Queen Elizabeth Hospital, Hong Kong, SAR, China
| | - Chung Ki Li
- Department of Medicine, Queen Elizabeth Hospital, Hong Kong, SAR, China
| | - Ka Foon Chau
- Department of Medicine, Queen Elizabeth Hospital, Hong Kong, SAR, China
| | - Wing Chi Fong
- Department of Medicine, Queen Elizabeth Hospital, Hong Kong, SAR, China
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Radecki RP, Azam A, Doshi PB, Banuelos RC. Iodinated contrast prior to thrombolysis was not associated with worse intracranial hemorrhage. Acad Emerg Med 2015; 22:259-63. [PMID: 25731593 DOI: 10.1111/acem.12603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 10/15/2014] [Accepted: 10/20/2014] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The objective was to assess relative incidence of clinical adverse effects between patients receiving, and not receiving, iodinated contrast prior to thrombolysis. METHODS This was a retrospective registry review of patients presenting to the emergency department treated with recombinant tissue-type plasminogen activator (rt-PA) for acute ischemic stroke between 2004 and 2012. The authors compared the occurrence of all grades of intracranial hemorrhage (ICH), symptomatic intracranial hemorrhage (sICH), and in-hospital deaths between patients undergoing computed tomographic angiography (CTA) prior to thrombolysis and those who did not. RESULTS A total of 1,014 patients were available for analysis meeting inclusion criteria. A total of 473 patients underwent CTA prior to rt-PA administration. Baseline characteristics were generally similar across groups, excepting fewer signs of acute infarct and old stroke in the CTA group (28.8% vs. 8.5% and 9.9% vs. 3.7%, respectively) and creatinine. Adverse event outcomes were not consistently distributed across the groups. Patients in the CTA group had a similar incidence of any ICH (11.0% vs. 8.1%, p = 0.120), but fewer type II parenchymal hemorrhages (2.1% vs. 4.6%, p = 0.025) and fewer in-hospital deaths (7.2% vs. 12.6%, p = 0.005). CONCLUSIONS No consistent harms were observed in association with intravenous iodinated contrast prior to rt-PA administration. It is reasonable to continue CTA prior to thrombolysis as clinically indicated.
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Affiliation(s)
- Ryan P. Radecki
- The Department of Emergency Medicine; The University of Texas Medical School at Houston; Houston TX
| | - Arif Azam
- The Department of Emergency Medicine; The University of Texas Medical School at Houston; Houston TX
| | - Pratik B. Doshi
- The Department of Emergency Medicine; The University of Texas Medical School at Houston; Houston TX
| | - Rosa C. Banuelos
- The Department of Emergency Medicine; The University of Texas Medical School at Houston; Houston TX
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Hao Z, Yang C, Liu M, Wu B. Renal dysfunction and thrombolytic therapy in patients with acute ischemic stroke: a systematic review and meta-analysis. Medicine (Baltimore) 2014; 93:e286. [PMID: 25526464 PMCID: PMC4603096 DOI: 10.1097/md.0000000000000286] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Renal dysfunction is a prevalent comorbidity in acute ischemic stroke patients requiring thrombolytic therapy. However, the effect of renal dysfunction on the clinical outcome of this population remains controversial. This study aimed to evaluate the safety and effectiveness of thrombolytic therapy in acute stroke patients with renal dysfunction using a meta-analysis. We systematically searched PubMed and EMBASE for studies that evaluated the relationship between renal dysfunction and intravenous tissue plasminogen activator (tPA) in patients with acute ischemic stroke. Poor outcome (modified Rankin Scale≥2), mortality, and symptomatic intracranial hemorrhage (ICH) and any ICH were analyzed. Fourteen studies were included (N=53,553 patients). The mean age ranged from 66 to 75 years. The proportion of male participants was 49% to 74%. The proportion of renal dysfunction varied from 21.9% to 83% according to different definitions. Based on 9 studies with a total of 7796 patients, the meta-analysis did not identify a significant difference in the odds of poor outcome (odds ratio [OR]=1.06; 95% confidence interval [CI]: 0.96-1.16; I=44.5) between patients with renal dysfunction and those without renal dysfunction. Patients with renal dysfunction were more likely to die after intravenous thrombolysis (OR=1.13; 95% CI: 1.05-1.21; I=70.3). No association was observed between symptomatic ICH (OR=1.02; 95% CI: 0.94-1.10; I=0) and any ICH (OR=1.07; 95% CI: 0.96-1.18; I=25.8). Renal dysfunction does not increase the risk of poor outcome and ICH after stroke thrombolysis. Renal dysfunction should not be a contraindication for administration of intravenous thrombolysis to eligible patients.
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Affiliation(s)
- Zilong Hao
- From the Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, No 37, Guo Xue Xiang, Chengdu 610041, China (ZH, ML, BW); Department of Pharmacy, Evidence-Based Pharmacy Center, West China Second Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Chengdu, 610041 China (CY)
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Miyagi T, Koga M, Yamagami H, Okuda S, Okada Y, Kimura K, Shiokawa Y, Nakagawara J, Furui E, Hasegawa Y, Kario K, Arihiro S, Sato S, Minematsu K, Toyoda K. Reduced estimated glomerular filtration rate affects outcomes 3 months after intracerebral hemorrhage: the stroke acute management with urgent risk-factor assessment and improvement-intracerebral hemorrhage study. J Stroke Cerebrovasc Dis 2014; 24:176-82. [PMID: 25440328 DOI: 10.1016/j.jstrokecerebrovasdis.2014.08.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 08/13/2014] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The effect of renal dysfunction on intracerebral hemorrhage (ICH) remains unclear. We investigated associations of renal dysfunction assessed by estimated glomerular filtration rate (eGFR) with clinical courses and outcomes in ICH patients. METHODS From a prospective, multicenter, observational study, 203 patients who had supratentorial ICH within 3 hours of onset were included. Patients were classified into 3 groups based on eGFR: Group 1 (eGFR < 60 mL/minute/m(2)), Group 2 (60-89), and Group 3 (≥ 90). Outcomes included neurologic deterioration within 72 hours, hematoma expansion (> 33% in volume) at 24 hours, and favorable (modified Rankin Scale [mRS] ≤ 2) or unfavorable (mRS ≥ 5) outcome at 3 months. RESULTS Thirty-seven patients (16 women, 74.6 ± 13.2 years) were assigned to Group 1, 99 (34 women, 65.2 ± 11.4 years) to Group 2, and 67 (30 women, 61.3 ± 9.4 years) to Group 3. Significant differences were found in age (P < .001) and initial systolic blood pressure among the groups (208.4 ± 18.0, 201.9 ± 15.1, and 198.1 ± 14.2 mm Hg for Group 1, 2, and 3, respectively; P = .006). Similar rates of neurologic deterioration (14%, 6%, and 6%) and hematoma expansion (16%, 14%, and 18%) were observed among the groups. However, in Group 1, favorable outcome was less frequent (17%, 48%, and 42%; P = .002) and unfavorable outcome was more frequent (24%, 7%, and 6%; P = .013) than in the other groups. After adjustment for confounders, eGFR < 60 mL/minute/m(2) was independently associated with both favorable outcome (odds ratio [OR], .21; 95% CI, .07-.54) and unfavorable outcome (OR, 5.64; 95% CI, 1.80-18.58). CONCLUSIONS Renal dysfunction (eGFR < 60 mL/minute/m(2)) was associated with poor clinical outcome after ICH.
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Affiliation(s)
- Tetsuya Miyagi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masatoshi Koga
- Department of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Japan.
| | - Hiroshi Yamagami
- Department of Neurology, Stroke Center, Kobe City General Hospital, Kobe, Japan
| | - Satoshi Okuda
- Department of Neurology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Yasushi Okada
- Department of Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Kazumi Kimura
- Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Yoshiaki Shiokawa
- Departments of Neurosurgery and Stroke Center, Kyorin University School of Medicine, Mitaka, Japan
| | - Jyoji Nakagawara
- Department of Neurosurgery and Stroke Center, Nakamura Memorial Hospital, Sapporo, Japan
| | - Eisuke Furui
- Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan
| | - Yasuhiro Hasegawa
- Department of Neurology, St Marianna University School of Medicine, Kawasaki, Japan
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan
| | - Shoji Arihiro
- Department of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Shoichiro Sato
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazuo Minematsu
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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El Husseini N, Kaskar O, Goldstein LB. Chronic kidney disease and stroke. Adv Chronic Kidney Dis 2014; 21:500-8. [PMID: 25443575 DOI: 10.1053/j.ackd.2014.09.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 09/05/2014] [Accepted: 09/05/2014] [Indexed: 12/19/2022]
Abstract
Chronic kidney disease (CKD) is associated with an increased risk of both ischemic and hemorrhagic stroke. In addition to shared risk factors, this higher cerebrovascular risk is mediated by several CKD-associated mechanisms including platelet dysfunction, coagulation disorders, endothelial dysfunction, inflammation, and increased risk of atrial fibrillation. CKD can also modify the effect of treatments used in acute stroke and in secondary stroke prevention. We review the epidemiology and pathophysiology that link CKD and stroke and the impact of CKD on stroke outcomes. Interdisciplinary collaboration between nephrologists, pharmacists, hematologists, nutrition therapists, primary care physicians, and neurologists in providing care to these subjects may potentially improve outcomes.
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Ovbiagele B, Smith EE, Schwamm LH, Grau-Sepulveda MV, Saver JL, Bhatt DL, Hernandez AF, Peterson ED, Fonarow GC. Chronic kidney disease and bleeding complications after intravenous thrombolytic therapy for acute ischemic stroke. CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES 2014; 7:929-35. [PMID: 25249561 DOI: 10.1161/circoutcomes.114.001144] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The safety of intravenous thrombolysis in ischemic stroke (IS) patients with chronic kidney disease (CKD) is uncertain. We assessed whether CKD is associated with bleeding complications after intravenous tissue-type plasminogen activator administration to patients with IS. METHODS AND RESULTS Data were analyzed from 44 410 patients with IS treated with intravenous tissue-type plasminogen activator in the Get With The Guidelines-Stroke Program. Glomerular filtration rate based on admission serum creatinine was categorized as dichotomous (presence of CKD as <60) or as distinct categories: normal (≥90), mild (≥60-<90), moderate (≥30-< 60), severe (≥15-<30), and kidney failure (<15 or dialysis). Primary outcomes evaluated were symptomatic intracranial hemorrhage and serious systemic hemorrhage; secondary outcomes were in-hospital mortality, independent functional status. There were 15 191 of 44 410 (34%) intravenous tissue-type plasminogen activator-treated IS patients with CKD. Presence of CKD (versus no CKD) was not associated with risk-adjusted symptomatic intracranial hemorrhage (adjusted odds ratio, 1.0; 95% confidence interval: 0.91-1.10) or serious systemic hemorrhage (adjusted odds ratio, 0.97; 95% confidence interval: 0.80-1.18) and did not significantly vary by kidney dysfunction stage for either of these primary end points in multivariable analyses. Compared with patients with normal kidney function, those with CKD were more likely to die in the hospital (adjusted odds ratio, 1.22; 95% confidence interval: 1.14-1.32) and have an unfavorable discharge functional status (adjusted odds ratio, 1.13; 95% CI: 1.07-1.19). CONCLUSIONS Presence of CKD among patients with IS treated with intravenous tissue-type plasminogen activator is associated with higher unadjusted odds of symptomatic intracranial hemorrhage or serious systemic hemorrhage, but this is explained by non-CKD related factors.
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Affiliation(s)
- Bruce Ovbiagele
- From the Department of Neurosciences, Medical University of South Carolina, Charleston (B.O.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Canada (E.E.S.); Division of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Outcomes Research and Assessment Group, Duke Clinical Research Institute, Durham, NC (M.V.G.-S., A.F.H., E.D.P.); Stroke Center and Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.).
| | - Eric E Smith
- From the Department of Neurosciences, Medical University of South Carolina, Charleston (B.O.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Canada (E.E.S.); Division of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Outcomes Research and Assessment Group, Duke Clinical Research Institute, Durham, NC (M.V.G.-S., A.F.H., E.D.P.); Stroke Center and Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.)
| | - Lee H Schwamm
- From the Department of Neurosciences, Medical University of South Carolina, Charleston (B.O.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Canada (E.E.S.); Division of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Outcomes Research and Assessment Group, Duke Clinical Research Institute, Durham, NC (M.V.G.-S., A.F.H., E.D.P.); Stroke Center and Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.)
| | - Maria V Grau-Sepulveda
- From the Department of Neurosciences, Medical University of South Carolina, Charleston (B.O.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Canada (E.E.S.); Division of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Outcomes Research and Assessment Group, Duke Clinical Research Institute, Durham, NC (M.V.G.-S., A.F.H., E.D.P.); Stroke Center and Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.)
| | - Jeffrey L Saver
- From the Department of Neurosciences, Medical University of South Carolina, Charleston (B.O.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Canada (E.E.S.); Division of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Outcomes Research and Assessment Group, Duke Clinical Research Institute, Durham, NC (M.V.G.-S., A.F.H., E.D.P.); Stroke Center and Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.)
| | - Deepak L Bhatt
- From the Department of Neurosciences, Medical University of South Carolina, Charleston (B.O.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Canada (E.E.S.); Division of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Outcomes Research and Assessment Group, Duke Clinical Research Institute, Durham, NC (M.V.G.-S., A.F.H., E.D.P.); Stroke Center and Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.)
| | - Adrian F Hernandez
- From the Department of Neurosciences, Medical University of South Carolina, Charleston (B.O.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Canada (E.E.S.); Division of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Outcomes Research and Assessment Group, Duke Clinical Research Institute, Durham, NC (M.V.G.-S., A.F.H., E.D.P.); Stroke Center and Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.)
| | - Eric D Peterson
- From the Department of Neurosciences, Medical University of South Carolina, Charleston (B.O.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Canada (E.E.S.); Division of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Outcomes Research and Assessment Group, Duke Clinical Research Institute, Durham, NC (M.V.G.-S., A.F.H., E.D.P.); Stroke Center and Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.)
| | - Gregg C Fonarow
- From the Department of Neurosciences, Medical University of South Carolina, Charleston (B.O.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Canada (E.E.S.); Division of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Outcomes Research and Assessment Group, Duke Clinical Research Institute, Durham, NC (M.V.G.-S., A.F.H., E.D.P.); Stroke Center and Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.)
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Laible M, Horstmann S, Rizos T, Rauch G, Zorn M, Veltkamp R. Prevalence of renal dysfunction in ischaemic stroke and transient ischaemic attack patients with or without atrial fibrillation. Eur J Neurol 2014; 22:64-9, e4-5. [PMID: 25091540 DOI: 10.1111/ene.12528] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 06/09/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Chronic kidney disease (CKD) is associated with a higher risk of stroke and atrial fibrillation (AF). There are limited data on the comorbidity of renal dysfunction and AF in stroke patients. Our aim was to determine the frequency of kidney dysfunction in ischaemic stroke patients with and without AF. METHODS In a prospectively collected, single center cohort of acute ischaemic stroke and transient ischaemic attack (TIA) patients, glomerular filtration rate (eGFR) was estimated using the Modification of Diet in Renal Disease equation on admission. Renal function was graded into five categories (cat.): cat. 1, eGRF ≥90 ml/min/1.73 m(2); cat. 2, 60-89; cat. 3, 30-59; cat. 4, 15-29; cat. 5, <15. The diagnosis of AF was based on medical history, a 12-lead electrocardiogram (ECG) and 24-h Holter or continuous ECG monitoring. RESULTS In total, 2274 patients (1727 stroke, 547 TIA; median age 71.0) were included. Median eGFR was 78.6 ml/min/1.73 m(2) (interquartile range 61/95); 21.1% were in cat. 3, 2.1% in cat. 4, 0.7% in cat. 5. In all, 535 patients (23.5%) suffered from AF; 28.0% of these were in cat. 3, 2.6% and 0.8% in cat. 4 and cat. 5, respectively. In multivariable analysis, age [odds ratio (OR) 1.1], diabetes (OR 1.8), heart failure (OR 1.7) and AF (OR 1.4) were independently associated with kidney dysfunction (eGFR < 60). CONCLUSIONS Renal dysfunction is far more common in stroke patients than in the general population and more common in AF-related stroke. These findings may have implications for the choice of anticoagulants.
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Affiliation(s)
- M Laible
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
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Toyoda K, Ninomiya T. Stroke and cerebrovascular diseases in patients with chronic kidney disease. Lancet Neurol 2014; 13:823-33. [DOI: 10.1016/s1474-4422(14)70026-2] [Citation(s) in RCA: 176] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Sauer EM, Sauer R, Kallmünzer B, Blinzler C, Breuer L, Huttner HB, Schwab S, Köhrmann M. Impaired Renal Function in Stroke Patients with Atrial Fibrillation. J Stroke Cerebrovasc Dis 2014; 23:1225-8. [DOI: 10.1016/j.jstrokecerebrovasdis.2013.10.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 10/22/2013] [Indexed: 11/24/2022] Open
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Rowat A, Graham C, Dennis M. Renal Dysfunction in Stroke Patients: A Hospital-Based Cohort Study and Systematic Review. Int J Stroke 2014; 9:633-9. [DOI: 10.1111/ijs.12264] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 01/14/2014] [Indexed: 12/01/2022]
Abstract
Background and purpose Renal dysfunction (i.e. a reduced estimated glomerular filtration rate, eGFR) is commonly found in hospitalized stroke patients but its associations with Patients' characteristics and outcome require further investigation. Methods We linked clinical data from stroke patients enrolled between 2005 and 2008 into two prospective hospital registers with routine laboratory eGFR data. The eGFR was calculated using the Modification of Diet in Renal Disease method and renal dysfunction was defined as <60 ml/min/1·73 m2. In addition we systematically reviewed studies investigating the association between eGFR and outcome after stroke. Results Of 2520 patients who had an eGFR measured on admission hospital, 805 (32%) had renal dysfunction. On multivariate analysis, renal dysfunction was significantly less likely in those with a predicted good outcome (OR 0·27, 95% CI 0·21, 0·36) based on the well-validated six simple variable model. After adjustment for other predictive factors, stroke patients with renal dysfunction were more likely to die in hospital compared with those without (odds ratio 1·59, 95% confidence intervals 1·26, 2·00). Of the 31 studies involving 41 896 participants included in the systematic review, 18 studies found that low eGFR was an independent predictor of death and 6 reported a significant association with death and disability. Conclusion Our findings suggest that renal dysfunction on admission is common and associated with poor outcomes over the first year. Further work is required to establish to what extent these associations are causal and whether treating impaired renal function improves outcomes.
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Affiliation(s)
- Anne Rowat
- SNMSC, Edinburgh Napier University, Edinburgh, UK
| | - Catriona Graham
- Western General Hospital, University of Edinburgh, Edinburgh, UK
| | - Martin Dennis
- Western General Hospital, University of Edinburgh, Edinburgh, UK
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Hsieh CY, Lin HJ, Sung SF, Hsieh HC, Lai ECC, Chen CH. Is renal dysfunction associated with adverse stroke outcome after thrombolytic therapy? Cerebrovasc Dis 2013; 37:51-6. [PMID: 24401854 DOI: 10.1159/000356348] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 10/14/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Renal dysfunction is a prevalent comorbidity in acute stroke patients requiring thrombolytic therapy. Reports studying the relationship between renal dysfunction and risk of postthrombolytic symptomatic intracerebral hemorrhage (SICH) are contradictory. We aimed to compare the safety and effectiveness of thrombolytic therapy in acute stroke patients with and without renal dysfunction. METHODS Based on the prospective stroke registries of 4 hospitals in Taiwan from 2007-2012, we identified acute stroke patients who received thrombolytic therapy. Clinically significant renal dysfunction was defined as an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m(2). Renal dysfunction was further defined as stage 3 (30 ≤ eGFR < 60 ml/min/ 1.73 m(2)), stage 4 (15 ≤ eGFR < 30 ml/min/1.73 m(2)) and stage 5 (<15 ml/min/1.73 m(2)). The rates of SICH and poor outcome (defined as modified Rankin scale score ≥4) at 3 months after thrombolytic therapy were compared in patients with and without renal dysfunction. SICH was determined according to the definition of the National Institute of Neurological Disorders and Stroke. Multivariable logistic regression was used to determine the effect of renal dysfunction on outcome. Patients with different stages of renal dysfunction were further analyzed to determine the effect of disease severity on outcome. RESULTS Of the 657 stroke patients with thrombolysis, 239 (36%) had renal dysfunction, including 212 patients in stage 3, 17 patients in stage 4 and 10 patients in stage 5 of renal dysfunction. Patients with renal dysfunction were older and more likely to have hypertension, ischemic heart disease, congestive heart failure and prior antiplatelet use than those without. There were no differences in SICH (8 vs. 7%, p = 0.580) and poor outcome (41 vs. 39%, p = 0.758) between patients with and without renal dysfunction. After multivariable analysis, renal dysfunction was not associated with SICH (odds ratio: 1.03, 95% confidence interval: 0.55-1.92) and poor outcome. Pretreatment stroke severity was the only factor significantly associated with both SICH and poor outcome at 3 months. When stratifying renal dysfunction into stage 3 and stage ≥4, there was no significant increase in SICH as the severity of renal dysfunction increased after multivariable adjustment. CONCLUSIONS Renal dysfunction did not increase the risk of SICH and poor outcome at 3 months after stroke thrombolysis. Further study comparing directly the risk and benefit of thrombolytic therapy versus no therapy in stroke patients with renal dysfunction is warranted.
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Affiliation(s)
- Cheng-Yang Hsieh
- Department of Neurology, Tainan Sin Lau Hospital, Tainan, Taiwan, ROC
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Power A, Fogarty D, Wheeler DC. Acute Stroke Thrombolysis in End-Stage Renal Disease: A National Survey of Nephrologist Opinion. ACTA ACUST UNITED AC 2013; 124:167-72. [DOI: 10.1159/000357155] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 10/29/2013] [Indexed: 11/19/2022]
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Chen CH, Tang SC, Tsai LK, Yeh SJ, Chen KH, Li CH, Hsiao YJ, Chen YW, Yip BS, Jeng JS. Proteinuria independently predicts unfavorable outcome of ischemic stroke patients receiving intravenous thrombolysis. PLoS One 2013; 8:e80527. [PMID: 24278288 PMCID: PMC3838417 DOI: 10.1371/journal.pone.0080527] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 10/14/2013] [Indexed: 11/26/2022] Open
Abstract
Background and Purpose Patients with low estimated glomerular filtration rate (eGFR) and proteinuria may be at increased risk for stroke. This study investigated whether low eGFR and proteinuria are outcome predictors in stroke patients treated with intravenous thrombolysis. Methods We studied 432 consecutive stroke patients who received thrombolysis from January 2006 to December 2012, in Taiwan. Unfavorable outcome was defined as modified Rankin scale ≥2 at 3 months after stroke. Proteinuria was classified as negative or trace, mild, and moderate to severe. Using logistic regression analysis, we identified independent factors for unfavorable outcome after thrombolysis. Results Of all patients, 32.7% had proteinuria. Patients with proteinuria were older, had higher frequencies of diabetes mellitus, hyperlipidemia, atrial fibrillation, lower eGFR, and greater severity of stroke upon admission than those without proteinuria. Proteinuria, not low eGFR, was an independent predictor for unfavorable outcome for stroke (OR = 2.00 for mild proteinuria, p = 0.035; OR = 2.54 for moderate to severe proteinuria, p = 0.035). However, no clear relationship was found between proteinuria and symptomatic hemorrhage after thrombolysis. Conclusions Proteinuria is an independent predictor of unfavorable outcome for acute ischemic stroke in patients treated with intravenous thrombolysis, indicating the crucial role of chronic kidney disease on the effectiveness of thrombolysis.
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Affiliation(s)
- Chih-Hao Chen
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
- Division of Neurology, Department of Internal Medicine, Far-Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Neurology, National Taiwan University Hospital Yun-Lin Branch, Yunlin, Taiwan
| | - Shin-Joe Yeh
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Kai-Hsiang Chen
- Department of Neurology, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Chen-Hua Li
- Department of Neurology, Landseed Hospital, Taoyuan, Taiwan
| | - Yu-Jen Hsiao
- Department of Neurology, National Taiwan University Hospital Yun-Lin Branch, Yunlin, Taiwan
| | - Yu-Wei Chen
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Neurology, Landseed Hospital, Taoyuan, Taiwan
| | - Bak-Sau Yip
- Department of Neurology, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
- * E-mail:
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Marsh EB, Gottesman RF, Hillis AE, Urrutia VC, Llinas RH. Serum creatinine may indicate risk of symptomatic intracranial hemorrhage after intravenous tissue plasminogen activator (IV tPA). Medicine (Baltimore) 2013; 92:317-323. [PMID: 24145699 PMCID: PMC4442012 DOI: 10.1097/md.0000000000000006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Symptomatic intracranial hemorrhage (sICH) is a known complication following administration of intravenous tissue plasminogen activator (IV tPA) for acute ischemic stroke. sICH results in high rates of death or long-term disability. Our ability to predict its occurrence is important in clinical decision making and when counseling families. The initial National Institute of Neurological Disorders and Stroke (NINDS) investigators developed a list of relative contraindications to IV tPA meant to decrease the risk of subsequent sICH. To date, the impact of renal impairment has not been well studied. In the current study we evaluate the potential association between renal impairment and post-tPA intracranial hemorrhage (ICH). Admission serum creatinine and estimated glomerular filtration rate (eGFR) were recorded in 224 patients presenting within 4.5 hours from symptom onset and treated with IV tPA based on NINDS criteria. Neuroimaging was obtained 1 day post-tPA and for any change in neurologic status to evaluate for ICH. Images were retrospectively evaluated for hemorrhage by a board-certified neuroradiologist and 2 reviewers blinded to the patient's neurologic status. Medical records were reviewed retrospectively for evidence of neurologic decline indicating a "symptomatic" hemorrhage. sICH was defined as subjective clinical deterioration (documented by the primary neurology team) and hemorrhage on neuroimaging that was felt to be the most likely cause. Renal impairment was evaluated using both serum creatinine and eGFR in a number of ways: 1) continuous creatinine; 2) any renal impairment by creatinine (serum creatinine >1.0 mg/dL); 3) continuous eGFR; and 4) any renal impairment by eGFR (eGFR <60 mL/min per 1.73 m²). Student paired t tests, Fisher exact tests, and multivariable logistic regression (adjusted for demographics and vascular risk factors) were used to evaluate the relationship between renal impairment and ICH. Fifty-seven (25%) of the 224 patients had some evidence of hemorrhage on neuroimaging. The majority of patients were asymptomatic. Renal impairment (defined by serum creatinine >1.0 mg/dL) was not associated with combined symptomatic and asymptomatic intracranial bleeding (p = 0.359); however, there was an adjusted 5.5-fold increased odds of sICH when creatinine was >1.0 mg/dL (95% confidence interval, 1.08-28.39), and the frequency of sICH for patients with elevated serum creatinine was 10.6% (12/113), versus 1.8% (2/111) in those with normal renal function (p = 0.010). Our study suggests that renal impairment is associated with higher risk of sICH after administration of IV tPA. As IV tPA is an important and effective treatment for acute ischemic stroke, a multicenter study is needed to determine whether the observation that renal dysfunction is associated with sICH from this retrospective study holds true in a larger prospective trial.
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Affiliation(s)
- Elisabeth B Marsh
- From the Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Tütüncü S, Ziegler AM, Scheitz JF, Slowinski T, Rocco A, Endres M, Nolte CH. Severe Renal Impairment Is Associated With Symptomatic Intracerebral Hemorrhage After Thrombolysis for Ischemic Stroke. Stroke 2013; 44:3217-9. [DOI: 10.1161/strokeaha.113.002859] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Serdar Tütüncü
- From the Departments of Neurology (S.T., A.M.Z., J.F.S., A.R., M.E., C.H.N.) and Nephrology (T.S.), Charité Universitaetsmedizin Berlin, Germany
| | - Annerose M. Ziegler
- From the Departments of Neurology (S.T., A.M.Z., J.F.S., A.R., M.E., C.H.N.) and Nephrology (T.S.), Charité Universitaetsmedizin Berlin, Germany
| | - Jan F. Scheitz
- From the Departments of Neurology (S.T., A.M.Z., J.F.S., A.R., M.E., C.H.N.) and Nephrology (T.S.), Charité Universitaetsmedizin Berlin, Germany
| | - Torsten Slowinski
- From the Departments of Neurology (S.T., A.M.Z., J.F.S., A.R., M.E., C.H.N.) and Nephrology (T.S.), Charité Universitaetsmedizin Berlin, Germany
| | - Andrea Rocco
- From the Departments of Neurology (S.T., A.M.Z., J.F.S., A.R., M.E., C.H.N.) and Nephrology (T.S.), Charité Universitaetsmedizin Berlin, Germany
| | - Matthias Endres
- From the Departments of Neurology (S.T., A.M.Z., J.F.S., A.R., M.E., C.H.N.) and Nephrology (T.S.), Charité Universitaetsmedizin Berlin, Germany
| | - Christian H. Nolte
- From the Departments of Neurology (S.T., A.M.Z., J.F.S., A.R., M.E., C.H.N.) and Nephrology (T.S.), Charité Universitaetsmedizin Berlin, Germany
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Tariq N, Adil MM, Saeed F, Chaudhry SA, Qureshi AI. Outcomes of Thrombolytic Treatment for Acute Ischemic Stroke in Dialysis-Dependent Patients in the United States. J Stroke Cerebrovasc Dis 2013; 22:e354-9. [DOI: 10.1016/j.jstrokecerebrovasdis.2013.03.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2013] [Revised: 03/02/2013] [Accepted: 03/14/2013] [Indexed: 10/26/2022] Open
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Chao TH, Lin TC, Shieh Y, Chang TY, Hung KL, Liu CH, Lee TH, Chang YJ, Lee JD, Chang CH. Intracerebral Hemorrhage after Thrombolytic Therapy in Acute Ischemic Stroke Patients with Renal Dysfunction. Eur Neurol 2013; 70:316-21. [DOI: 10.1159/000353296] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 05/16/2013] [Indexed: 11/19/2022]
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Zhang Y, Churilov L, Meretoja A, Teo S, Davis SM, Yan B. Elevated urea level is associated with poor clinical outcome and increased mortality post intravenous tissue plasminogen activator in stroke patients. J Neurol Sci 2013; 332:110-5. [DOI: 10.1016/j.jns.2013.06.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 06/22/2013] [Accepted: 06/27/2013] [Indexed: 10/26/2022]
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Sobolewski P, Kozera G, Kaźmierski R, Michalak S, Szczuchniak W, Śledzińska-Dźwigał M, Nyka WM. Intravenous rt-PA in patients with ischaemic stroke and renal dysfunction. Clin Neurol Neurosurg 2013; 115:1770-4. [PMID: 23643179 DOI: 10.1016/j.clineuro.2013.04.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2013] [Revised: 03/25/2013] [Accepted: 04/08/2013] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Renal dysfunction (RD) increases risk for ischaemic stroke (IS). The impact of RD on the effects of iv-thrombolysis in the Caucasian population has not been fully determined. AIMS To evaluate the associations between RD and the outcome of iv-thrombolysis in Caucasian patients with IS. METHODS The observational, multicentre study included 404 patients with IS who were treated with iv-thrombolysis. RD was defined as estimated glomerular filtration rate ≤ 60 ml/min/1.73 m(2). Outcome was assessed with modified Rankin Score at 3 months after the stroke onset. RESULTS Medians baseline NIHSS score did not differ between groups of patients with and without RD (12.0 vs. 11.0 pts, p=0.33). Unfavourable outcome was found in 52.1% of patients with and in 41.2% of patients without RD (p=0.05), mortality was higher in patients with RD (29.9% vs. 14.3%, p<0.001), and the presence of haemorrhagic transformation (HT) did not differ between the groups (17.1% vs. 17.1% respectively, p=0.996). A multivariate analysis showed no impact of RD on the unfavourable outcome (OR 0.98; 95%CI 0.88-1.10), mortality (OR 0.92; 95%CI 0.81-1.05) or presence of HT (OR 1.03; 95%CI 0.90-1.18). CONCLUSIONS We found no impact of RD on the safety and efficacy of iv-thrombolysis in Caucasian patients with IS.
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Affiliation(s)
- P Sobolewski
- Department of Neurology and Stroke Unit of Hospital in Sandomierz, Sandomierz, Poland.
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McCloskey M, Masengu A, Shields J, Wiggam MI. Acute stroke in a patient with advanced uraemia: should thrombolysis be given? BMJ Case Rep 2013; 2013:bcr-2012-007307. [PMID: 23355564 DOI: 10.1136/bcr-2012-007307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 65-year-old gentleman with stage 5 chronic kidney disease developed an acute posterior circulation stroke, which was treated with intravenous thrombolytic therapy. This was complicated by a retroperitoneal haemorrhage. The patient made an excellent neurological recovery and was discharged to home, independently mobile, having been established on haemodialysis. This case highlights the challenges of managing acute ischaemic stroke in patients with advanced uraemia.
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Power A, Epstein D, Cohen D, Bathula R, Devine J, Kar A, Taube D, Duncan N, Ames D. Renal Impairment Reduces the Efficacy of Thrombolytic Therapy in Acute Ischemic Stroke. Cerebrovasc Dis 2013; 35:45-52. [DOI: 10.1159/000345071] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Accepted: 10/11/2012] [Indexed: 11/19/2022] Open
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Liu D, Ding H, Liu S, Shen J. Estimated glomerular filtration rate decline in 567 patients with acute stroke. ACTA ACUST UNITED AC 2011; 46:142-7. [PMID: 22171670 DOI: 10.3109/00365599.2011.639032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Diange Liu
- Department of Nephrology, First Affiliated Hospital of Harbin Medical University,
Harbin, China
- Departments Nephrology
| | | | - Shaohua Liu
- Departments Neurology, Zhongda Hospital,
Southeast University School of Medicine, Nanjing, China
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Naganuma M, Mori M, Nezu T, Makihara N, Koga M, Okada Y, Minematsu K, Toyoda K. Intravenous recombinant tissue plasminogen activator therapy for stroke patients receiving maintenance hemodialysis: the Stroke Acute Management with Urgent Risk-Factor Assessment and Improvement (SAMURAI) rt-PA registry. Eur Neurol 2011; 66:37-41. [PMID: 21709420 DOI: 10.1159/000328792] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Accepted: 04/26/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND To examine the therapeutic effect of intravenous recombinant tissue plasminogen activator (rt-PA) therapy for stroke patients receiving maintenance hemodialysis (HD). methods: Of 600 stroke patients receiving intravenous rt-PA using 0.6 mg/kg alteplase who were enrolled in a multicenter observational study in Japan, 4 patients (3 men, 64-77 years old) on maintenance HD were studied. RESULTS The primary kidney disease requiring HD was glomerulonephritis in 2 patients, diabetic nephropathy in 1, and undetermined in 1. The duration of HD ranged between 1.2 and 28 years. Three patients developed stroke on the day of HD, including 1 during HD and another just after HD. All patients had stroke in the carotid arterial territory. Pretreatment NIH Stroke Scale scores ranged between 4 and 20, and decreased by 2-5 points at 7 days. One patient needed intravenous antihypertensive therapy before rt-PA; he developed an ectopic cortical hematoma and intraventricular hemorrhage after rt-PA. The other 3 did not develop hemorrhagic complications. The modified Rankin Scale score at 3 months was 0 in 1 patient, 2 in 2 patients, and 4 in 1 patient. CONCLUSIONS rt-PA therapy for stroke patients receiving maintenance HD might improve the stroke outcome. Ectopic hematoma was a unique complication in our case series.
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Affiliation(s)
- Masaki Naganuma
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Fujishirodai 5-7-1, Suita, Japan
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Palacio S, Gonzales NR, Sangha NS, Birnbaum LA, Hart RG. Thrombolysis for acute stroke in hemodialysis: international survey of expert opinion. Clin J Am Soc Nephrol 2011; 6:1089-93. [PMID: 21393487 DOI: 10.2215/cjn.10481110] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Although data are absent, it has been stated that thrombolysis is probably not safe in the treatment of acute stroke in patients undergoing hemodialysis. The objective of this study was for stroke experts to define the range of management concerning thrombolytic treatment of acute stroke in hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Sixty-five stroke experts in thrombolytic therapy of acute ischemic stroke were queried regarding their personal experience in the use of thrombolysis in hemodialysis patients. Hypothetical case scenarios were presented. RESULTS Of the 65 stroke experts who were queried, 40 (62%) responded. One-third of the responders had previously treated hemodialysis patients with recombinant tissue-type plasminogen activator (rt-PA). Most favored use of intravenous rt-PA for hemodialysis patients with acute ischemic stroke. When presented with a case of a patient who had recently undergone dialysis with a mildly prolonged activated partial thromboplastin time (aPTT), 50% favored immediate intravenous thrombolysis. Seventy-eight percent of the experts would have considered an intra-arterial approach and would have preferred mechanical clot retrieval to thrombolysis. CONCLUSIONS Despite the acknowledged absence of data and prevalent concerns about bleeding risk, most surveyed experts favored its use. One-third reported treating hemodialysis patients with this therapy. Although these results do not substitute for data, they usefully define the range of current practice of stroke experts.
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Affiliation(s)
- Santiago Palacio
- Department of Neurology, University of Texas Health Science Center, 8300 Floyd Curl Drive MC# 7883, San Antonio, TX 78229-3900, USA.
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