Impact of Admission Hypertension on Rates of Acute Kidney Injury in Intracerebral Hemorrhage Treated with Intensive Blood Pressure Control

Predictive model of acute kidney injury after spontaneous intracerebral hemorrhage: A multicenter retrospective study

BACKGROUND AND OBJECTIVES

Acute kidney injury is a common comorbidity in patients with intracerebral hemorrhage. Although there are predictive models to determine risk of AKI in patients in critical care or post-surgical scenarios or in general medical floors, there are no models that specifically determine the risk of AKI in patients with ICH.

METHODS

Clinical features and laboratory tests were selected by previous studies and LASSO (least absolute shrinkage and selection operator) regression. We used multivariable logistic regression with a bidirectional stepwise method to construct ICH-AKIM (intracerebral hemorrhage-associated acute kidney injury model). The accuracy of ICH-AKIM was measured by the area under the receiver operating characteristic curve. The outcome was AKI development during hospitalization, defined as KDIGO (Kidney Disease: Improving Global Outcomes) Guidelines.

RESULTS

From four independent medical centers, a total of 9649 patients with ICH were available. Overall, five clinical features (sex, systolic blood pressure, diabetes, Glasgow coma scale, mannitol infusion) and four laboratory tests at admission (serum creatinine, albumin, uric acid, neutrophils-to-lymphocyte ratio) were predictive factors and were included in the ICH-AKIM construction. The AUC of ICH-AKIM in the derivation, internal validation, and three external validation cohorts were 0.815, 0.816, 0.776, 0.780, and 0.821, respectively. Compared to the univariate forecast and pre-existing AKI models, ICH-AKIM led to significant improvements in discrimination and reclassification for predicting the incidence of AKI in all cohorts. An online interface of ICH-AKIM is freely available for use.

CONCLUSION

ICH-AKIM exhibited good discriminative capabilities for the prediction of AKI after ICH and outperforms existing predictive models.

Associations of systolic blood pressure and in-hospital mortality in critically ill patients with acute kidney injury

PURPOSE

Although systolic blood pressure (SBP) is associated with acute renal injury (AKI), the relationship between baseline SBP and prognosis in critically ill patients with AKI is unclear. We aimed to assess the linearity and profile of the relationship between SBP at intensive care unit (ICU) admission and in-hospital mortality in these patients.

METHODS

Data of AKI patients in the ICU settings were extracted from the Medical Information Mart for Intensive Care III database. The association between seven SBP categories (< 100, 100-109, 110-119, 120-129, 130-139, 140-149, and ≥ 150 mmHg) and all-cause in-hospital mortality was assessed by Cox proportional hazard models. Restricted cubic spline analysis for the multivariate Cox model was performed to explore the shape of the relationship between SBP and mortality.

RESULTS

A total of 24,202 patients with AKI were included in this study. A typically U-shaped relationship was found between SBP at admission and in-hospital mortality. Among all SBP categories, the lowest risk of death was observed in patients with SBP around 110-119 mmHg, whereas the highest was noted in patients with extremely low SBP (< 100 mmHg), followed by those with extremely high SBP (≥ 150 mmHg). SBP showed a significant interaction with vasopressor use and AKI stage in relation to the risk of in-hospital mortality.

CONCLUSIONS

SBP upon admission showed a non-linear association with all-cause in-hospital mortality in critically ill patients with AKI. Patients with low or high SBP show an increased risk of mortality compared to patients with normal SBP.

Systolic Blood Pressure Variability When Transitioning From Intravenous to Enteral Antihypertensive Agents in Patients With Hemorrhagic Strokes

Background/Objective

Systolic blood pressure variability (SBPV) in patients with intracranial hemorrhage (ICH) and subarachnoid hemorrhage (SAH) is associated with an increased risk of acute kidney injury (AKI) and mortality. SBPV is a strong predictor of poor functional outcomes in patients with ICH. Intravenous (IV) antihypertensive agents are commonly used to achieve sustained target blood pressure goals; however, this is not a feasible long-term option. The transition from IV to enteral antihypertensives is not yet well established in patients with ICH and SAH. This study aimed to assess the effect of the number of antihypertensive agents and overlap time during the transition period from IV to enteral route on SBPV in patients with ICH and SAH.

Methods

This retrospective single-center study was conducted at a tertiary teaching hospital in Riyadh, Saudi Arabia. Data were extracted from electronic medical records after obtaining Institutional Review Board approval. Patients were included if they were &gt;18 years old, admitted with spontaneous ICH or SAH, and received continuous infusion antihypertensives prior to transitioning to the enteral route. The major outcome was the effect of the number of antihypertensive agents and overlap time on SBPV during the transition process. Minor outcomes included the effect of the number of antihypertensive agents and overlap time on heart rate variability and the incidence of AKI on day 7.

Results

After the screening, we included 102 patients. Based on our regression model, the number of enteral antihypertensive agents upon transitioning from IV to enteral antihypertensive therapy had no effect on SBPV in the intensive care unit (ICU) among our patients (p-value = 0.274). However, the prolonged overlap was associated with reduced SBPV in the ICU (p-value = 0.012). No differences were observed between the groups in heart rate variation or AKI rate.

Conclusions

In patients with ICH and SAH, prolonged overlap of enteral antihypertensive agents to overlap with intravenous antihypertensive therapy may result in lower SBPV. This finding needs to be confirmed on a larger scale with more robust study designs for patients with ICH and SAH.

Initial antihypertensive agent effects on acute blood pressure after intracerebral haemorrhage

Introduction

Current guidelines recommend blood pressure (BP) lowering in patients after acute intracerebral haemorrhage (ICH) without guidance on initial choice of antihypertensive class. This study sought to determine if initial antihypertensive class differentially effects acute BP lowering in a large multiethnic ICH cohort.

Methods

Subjects enrolled in the Ethnic/Racial Variations in ICH study between August 2010 and August 2017 with elevated admission BP and who received labetalol, nicardipine or hydralazine monotherapy as initial antihypertensive were analysed. Primary outcomes were systolic and diastolic BP changes from baseline to first BP measurement after initial antihypertensive treatment. Secondary outcomes included haematoma expansion (HE), hospital length of stay (LOS) and modified Rankin Score (mRS) up to 12 months after ICH. Exploratory outcomes assessed effects of race/ethnicity. Linear and logistic regression analyses, adjusted for relevant covariates, were performed to determine associations of antihypertensive class with outcomes.

Results

In total, 1156 cases were used in analyses. Antihypertensive class was associated with diastolic BP change (p=0.003), but not systolic BP change (p=0.419). Initial dosing with nicardipine lowered acute diastolic BP than labetalol (least square mean difference (labetalol-nicardipine)=5.47 (2.37, 8.57), p<0.001). Initial antihypertensive class was also found to be associated with LOS (p=0.028), but not with HE (p=0.406), mortality (p=0.118), discharge disposition (p=0.083) or mRS score at discharge, 3, 6 and 12 months follow-up (p=0.262, 0.276, 0.152 and 0.36, respectively). Race/ethnicity variably affected multivariable models.

Conclusion

In this large acute ICH cohort, initial antihypertensive class was associated with acute diastolic, but not systolic, BP-lowering suggesting differential effects of antihypertensive agents.

Trial registration number

NCT01202864.

Long-Term Mortality Related to Acute Kidney Injury Following Intracerebral Hemorrhage: A 10-Year (2010-2019) Retrospective Study

OBJECTIVES

Acute kidney injury (AKI) following intracerebral hemorrhage (ICH) is an intractable medical complication and an independent predictor of short-term mortality. However, the correlation between AKI and long-term mortality has not been fully investigated. The aim of the present study was to determine the relationship between AKI following ICH and long-term mortality in a 10-year (2010-2019) retrospective cohort.

MATERIALS AND METHODS

A total of 1449 ICH patients were screened and enrolled at the Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University) from January 2010 to December 2016. The endpoint for follow-up was May 31, 2019. The estimated all-cause mortality was determined using Cox proportional hazard regression models.

RESULTS

Among 1449 ICH patients, 136 (9.4%) suffered from AKI, and the duration of follow-up was a median of 5.1 years (IQR 3.2-7.2). The results indicated that the risk factors for AKI without preexisting chronic kidney disease (CKD) in the multivariable analysis were age (p = 0.002), nephrotoxic antibiotics (p = 0.000), diabetes mellitus (p = 0.005), sepsis (p = 0.000), antiplatelet therapy (p = 0.002), infratentorial hemorrhage (p = 0.000) and ICH volume (p = 0.003). Age (p = 0.008), ACEIs/ARBs (p = 0.010), nephrotoxic antibiotics (p = 0.014), coronary artery disease (p = 0.009), diabetes mellitus (p = 0.014), hypertension (p = 0.000) and anticoagulant therapy (p = 0.000) were independent predictors of AKI with preexisting CKD. Meanwhile, the data demonstrated that the estimated all-cause mortality was significantly higher in ICH patients with AKI without preexisting CKD (HR 4.208, 95% CI 2.946-6.011; p = 0.000) and in ICH patients with AKI with preexisting CKD (HR 2.470, 95% CI 1.747-3.492; p = 0.000) than in those without AKI.

CONCLUSIONS

AKI is a long-term independent predictor of mortality in ICH patients. Thus, renal function needs to be routinely determined in ICH patients during clinical practice.

Effect of Race-Ethnicity and CT Angiography on Renal Injury During Blood Pressure Treatment for Intracerebral Hemorrhage

BACKGROUND

Lowering blood pressure intensively in acute intracerebral hemorrhage (ICH) is associated with adverse renal events; Blacks and Hispanics have a higher incidence of ICH and kidney disease than Whites. In addition, CT angiography (CTA), which may also be associated with acute kidney injury (AKI), is often done in acute ICH. Our objective was to investigate the relationship between aggressive BP management, CTA, race-ethnicity and the risk of developing AKI in patients presenting with ICH.

METHODS

We retrospectively calculated the difference between the highest and lowest systolic blood pressure during the first 24 h of admission in patients with spontaneous ICH over 30 months. Creatinine (Cr) levels at admission were compared to the highest Cr level during the first 7 days after admission. AKI was defined as any > 50% increase of baseline Cr during the first 7 days. Logistic regression models were used to assess the association between race-ethnicity and CTA and AKI. We also analyzed the incidence of AKI stratified by race-ethnicity.

RESULTS

A total of 394 patients were included (mean age ± SD 63 ± 14 years), 160 patients (41%) were women, 162 (41%) Hispanic, 39 (10%) White and 189 (48%) Black. Most of the patients underwent CTA (73%). The prevalence of AKI was (18%), but no difference was found in AKI incidence (19% in Blacks vs. 17% in Whites vs. 18% in Hispanics (p = 0.940). In fully adjusted models, AKI was not associated with race-ethnicity (p = 0.665) or CTA (p = 0.187). The stratified analysis by race-ethnicity did not change our findings.

CONCLUSION

We found no association between race-ethnicity or CTA and AKI during the acute management of ICH in a real-life stroke population. Our findings suggest that CTA can be safely obtained in acute ICH, even in populations of diverse race-ethnicity who may be more prone to adverse kidney events. CTA did not contribute to developing AKI.

Systolic Blood Pressure Reduction and Acute Kidney Injury in Intracerebral Hemorrhage

BACKGROUND AND PURPOSE

We determined the rates and predictors of acute kidney injury (AKI) and renal adverse events (AEs), and effects of AKI and renal AEs on death or disability in patients with intracerebral hemorrhage.

METHODS

We analyzed data from a multicenter trial which randomized 1000 intracerebral hemorrhage patients with initial systolic blood pressure ≥180 mm Hg to intensive (goal 110-139 mm Hg) over standard (goal 140-179 mm Hg) systolic blood pressure reduction within 4.5 hours of symptom onset. AKI was identified by serial assessment of daily serum creatinine for 3 days post randomization.

RESULTS

AKI and renal AEs were observed in 149 patients (14.9%) and 65 patients (6.5%) among 1000 patients, respectively. In multivariate analysis, the higher baseline serum creatinine (≥110 μmol/L) was associated with AKI (odds ratio 2.4 [95% CI, 1.2-4.5]) and renal AEs (odds ratio 3.1 [95% CI, 1.2-8.1]). Higher area under the curve for intravenous nicardipine dose was associated with AKI (odds ratio 1.003 [95% CI, 1.001-1.005]) and renal AEs (odds ratio 1.003 [95% CI, 1.001-1.006]). There was a higher risk to death (relative risk 2.6 [95% CI, 1.6-4.2]) and death or disability (relative risk 1.5 [95% CI, 1.3-1.8]) at 90 days in patients with AKI but not in those with renal AEs.

CONCLUSIONS

Intracerebral hemorrhage patients with higher baseline serum creatinine and those receiving higher doses of nicardipine were at higher risk for AKI and renal AEs. Occurrence of AKI was associated higher rates of death or disability at 3 months. Registration: URL: https://clinicaltrials.gov. Unique identifier: NCT01176565.

An Association Between Hyperchloremia and Acute Kidney Injury in Patients With Acute Ischemic Stroke

Background and Purpose

While an association between hyperchloremia and worse outcomes, such as acute kidney injury and increased mortality, has been demonstrated in hemorrhagic stroke, it is unclear whether the same relationship exists after acute ischemic stroke. This study aims to determine the relationship between moderate hyperchloremia (serum chloride ≥115 mmol/L) and acute kidney injury in patients with ischemic stroke.

Methods

This is a multicenter, retrospective, propensity-matched cohort study of adults admitted for acute ischemic stroke. The primary objective was to determine the relationship between moderate hyperchloremia and acute kidney injury, as defined by the Acute Kidney Injury Network criteria. Secondary objectives included mortality and hospital length of stay.

Results

A total of 407 patients were included in the unmatched cohort (332 nonhyperchloremia and 75 hyperchloremia) and 114 patients (57 in each group) were matched based upon propensity scores. In the matched cohort, hyperchloremia was associated with an increased risk of acute kidney injury (relative risk 1.91 [95% confidence interval 1.01-3.59]) and a longer hospital length of stay (16 vs 12 days; P = .03). Mortality was higher in the hyperchloremia group (19.3% vs 10.5%, P = .19), but this did not reach statistical significance.

Conclusions

In this study, hyperchloremia after ischemic stroke was associated with increased rates of acute kidney injury and longer hospital length of stay. Further research is needed to determine which interventions may increase chloride levels in patients with acute ischemic stroke and the association between hyperchloremia and clinical outcomes.

Acute Blood Pressure Management in Neurocritically Ill Patients

Optimal blood pressure (BP) management is controversial in neurocritically ill patients due to conflicting concerns of worsening ischemia with decreased BP versus cerebral edema and increased intracranial pressure with elevated BP. In addition, high-quality evidence is lacking regarding optimal BP goals in patients with most of these conditions. This review summarizes guideline recommendations and examines the literature for BP management in patients with ischemic stroke, intracerebral hemorrhage, aneurysmal subarachnoid hemorrhage, traumatic brain injury, and spinal cord injury.