Renal Dysfunction and In-Hospital Outcomes in Patients With Acute Ischemic Stroke After Intravenous Thrombolytic Therapy

Chronic kidney disease prevalence and clinical outcomes in anterior circulation acute ischemic stroke patients with reperfusion therapy: A meta-analysis

AIM

Chronic Kidney Disease (CKD) is a common comorbidity among acute ischaemic stroke (AIS) patients undergoing reperfusion therapies, including intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT). Acknowledging CKD's prevalence in this cohort and understanding its influence on outcomes is crucial for prognosis and optimizing care. This study aims to determine the prevalence of CKD among anterior circulation AIS (acAIS) patients undergoing reperfusion therapies and to analyse the role of CKD in mediating outcomes.

METHODS

A random-effects meta-analysis was conducted to pool and examine prevalence data. A total of 263 633 patients were included in the meta-analysis. The study assessed CKD's association with functional outcomes, symptomatic intracranial haemorrhage (sICH) and mortality.

RESULTS

The overall pooled prevalence of CKD among acAIS ranged from 30% to 56% in IVT-treated patients and 16%-42% for EVT-treated patients. CKD was associated with increased odds of unfavourable functional outcome at 90 days in both IVT (OR 1.837; 95% CI: [1.599; 2.110]; p < .001) and EVT (OR 1.804; 95% CI: [1.525; 2.133]; p < .001) groups. In IVT-treated patients, CKD was associated with increased odds of 30-day mortality (OR 6.211; 95% CI: [1.105; 34.909]; p = .038). CKD in IVT-treated patients exhibited increased odds of sICH, albeit statistically non-significant (OR 1.595; 95% CI: [0.567; 3.275]).

CONCLUSIONS

The high prevalence of CKD and its significant impact on outcomes in acAIS patients treated with reperfusion therapies underscore its clinical significance. This insight can guide personalised care strategies and potentially improve the prognosis in the management of acAIS.

Risk factors for the outcome after thrombolysis in acute ischemic stroke - the prominent role of kidney dysfunction: A retrospective cohort observational study

A complex interplay of factors reflecting the general biological, cardiovascular, neurological, renal, and metabolic status of patients influences the outcome of thrombolysis in stroke patients. This is a retrospective cohort observational study aimed to determine the importance of kidney dysfunction among these factors. Data (demographic, lifestyle, physical examination, laboratory, imaging, including metabolic and cardiovascular risk factors and comorbidities, neurological scores, and outcomes) of all stroke patients who underwent thrombolysis have been registered since January 1, 2016, in an online database. A total of 296 patients registered until December 31, 2020, were included in the study. The National Institutes of Health Stroke Scale, modified Rankin scale, Barthel index, percentage of hemorrhagic transformation, and in hospital death were used to evaluate the neurological status and outcomes of the patients. Regression analysis, Mann-Whitney test, Fisher exact test, logistic regression, and multivariate analysis were used for statistical analysis. Kidney dysfunction, as reflected by the estimated glomerular filtration rate, was associated with in hospital death and all but one of the neurological scores. Other risk factors most frequently associated with neurological scores were age, international normalized ratio, and cognitive decline. Multivariate analysis revealed estimated glomerular filtration rate (as determined by chronic kidney disease-EPI equation) as a determinant for all but one of these scores, and as the most important determinant for most of them, except for those reflecting the pre-intervention neurological status of the patient. Kidney dysfunction seems to be the most important determinant of the outcome of thrombolysed stroke patients, a result obtained by no other study.

Pre-Stroke Loop Diuretics and Anemia in Elderly Patients Are Associated Factors of Severe Renal Dysfunction at the Time of Acute Stroke Onset

BACKGROUND

Severe renal dysfunction (SRD), an advanced stage of chronic kidney disease (CKD), can limit the treatment options for acute stroke (AS) patients. Therefore, it is important to investigate the associated factors of SRD in AS patients to inhibit CKD progression to SRD before AS. Sex differences exist in the renal function. Therefore, we investigated the frequency of SRD and its associated factors among AS patients by sex.

METHODS

Our cross-sectional study included patients admitted within 24 h of AS onset between 2013 and 2019 with available pre-stroke medication information. We used the Cockcroft-Gault equation for calculating the creatinine clearance (Ccr) and defined SRD as a Ccr < 30 mL/min. We performed multivariable logistic regression analysis to identify the independent factors associated with SRD.

RESULTS

Out of 4294 patients, 3472 matched our criteria. Of these, 1905 (54.9%) were male, with median ages of 75 and 81 years for males and females, respectively. The frequency of SRD was 9.7% in males and 18.7% in females. Loop diuretics and anemia were associated factors of SRD.

CONCLUSIONS

Pre-stroke loop diuretics and anemia in elderly patients were associated factors of SRD in both sexes. Individualized drug therapy and anemia management are essential to prevent SRD.

Intravenous Thrombolysis Improves the Prognosis of Patients with Acute Ischemic Stroke and Chronic Kidney Disease

BACKGROUND

Chronic kidney disease (CKD) is associated with a higher mortality rate and a poor prognosis among patients with acute ischemic stroke (AIS) who receive intravenous thrombolysis (IVT); however, it is still unclear whether IVT improves the prognosis of patients with AIS and CKD.

OBJECTIVE

We conducted this study to evaluate the impact of IVT in patients with AIS and CKD.

METHODS

We analyzed patients with AIS and CKD in 3 stroke centers who met the indications for IVT between January 2015 and January 2020. The patients were grouped into an IVT group and a non-IVT group according to whether patients received IVT. After propensity score matching at a 1:1 ratio, symptomatic intracranial hemorrhage (sICH) and the modified Rankin Scale (mRS) score at 3 months were compared to assess the safety and efficacy of IVT in patients with AIS with CKD.

RESULTS

A total of 888 patients were enrolled: 763 in the IVT group and 125 in the non-IVT group. After matching, 250 patients were analyzed, and no significant differences were found in sICH between the 2 groups. However, the IVT group had a better 90-day mRS (0-2) score (70.4% vs. 57.6; p = 0.048) than the non-IVT group.

CONCLUSIONS

IVT improved the 3-month prognosis and did not increase the occurrence of sICH among patients with AIS with CKD.

Effects of estimated glomerular filtration rate on clinical outcomes in patients with intracerebral hemorrhage

BACKGROUND

The influence of chronic kidney disease (CKD) on the severity and prognosis of spontaneous intracerebral hemorrhage (ICH) has been scarcely investigated. We aimed to explore the association of admission estimated glomerular filtration rate (eGFR) levels with hemorrhagic stroke severity and outcomes in ICH patients.

MATERIALS AND METHODS

The patients enrolled in this study were from the China Stroke Center Alliance study (CSCA). Patients were divided into four groups according to differences in eGFR at admission (≥90; 60-89; 45-59; < 45). Multivariable logistic regression analysis was used to determine the association of the eGFR at admission with hemorrhagic stroke severity, in-hospital complications, discharge disposition, and in-hospital mortality after ICH.

RESULTS

A total of 85,167 patients with acute ICH were included in the analysis. Among them, 9493 (11.1%) had a baseline eGFR<60 ml/min/1.73 m2. A low eGFR was associated with an increased risk of in-hospital mortality [eGFR 60-89 ml/min/1.73 m2, odds ratio (OR) 1.36 (95% confidence interval (CI) 1.21-1.53); eGFR 45-59, 2.35 (1.97-2.82); eGFR<45, 4.18 (3.7-4.72); P for trend < 0.0001], non-routine discharge [eGFR 60-89, 1.11 (1.03-1.2); eGFR 45-59, 1.16 (1-1.35); eGFR<45, 1.37 (1.23-1.53); P for trend < 0.0001], hemorrhagic stroke severity [eGFR 60-89, 1 (0.95-1.05); eGFR 45-59, 1.39 (1.26-1.53); eGFR<45, 1.81 (1.67-1.96); P for trend < 0.0001], in-hospital complications of pneumonia [eGFR 60-89, 1.1 (1.05-1.14); eGFR 45-59, 1.3 (1.2-1.4); eGFR<45, 1.66 (1.57-1.76); P for trend < 0.0001] and hydrocephalus [eGFR 60-89, 0.99 (0.87-1.12); eGFR 45-59, 1.37 (1.1-1.7); eGFR<45, 1.54 (1.32-1.8); P for trend = 0.0139] after adjusting for confounding factors. With the decline in eGFR, the risk of hematoma evacuation increased in patients with an eGFR 45 to 59 ml/min/1.73 m2 (OR 1.48; 95% CI 1.37-1.61). No significant association between differences in eGFR at baseline and in-hospital complication of recurrent intracerebral hemorrhage was observed.

CONCLUSIONS

Low eGFR at baseline was associated with an increased risk of in-hospital mortality, non-routine discharge, hemorrhagic stroke severity and in-hospital complications such as pneumonia, hydrocephalus and hematoma evacuation in acute ICH patients.

Thrombolysis in acute ischaemic stroke patients with chronic kidney disease

OBJECTIVE

We aimed to determine whether chronic kidney disease (CKD) is associated with adverse in-hospital outcomes after acute ischaemic stroke (AIS) and whether this association is dependent on thrombolysis administration.

METHODS

885,537 records representative of 4,283,086 AIS admissions were extracted from the US National Inpatient Sample (2005-2015) and categorized into 3 mutually exclusive groups: no CKD, CKD without end-stage renal disease (ESRD) and ESRD. Outcomes (mortality, prolonged hospitalisation >4 days and disability on discharge-derived using discharge destination as a proxy) were compared between groups using multivariable logistic regressions. Separate models containing interaction terms with thrombolysis were also computed.

RESULTS

The median age (interquartile range) of the cohort was 73 (61-83) years and 47.32% were men. Compared with the no CKD group, both CKD/no ESRD group (odds ratio (99% confidence interval) = 1.04 (1.0003-1.09), p = 0.009) and the ESRD groups (2.06 (1.90-2.25), p < 0.001) had significantly increased odds of in-hospital mortality. Patients with CKD/No ESRD (1.03 (1.02-1.06), p < 0.001) and ESRD (1.44 (1.37-1.51), p < 0.001) were at higher odds of prolonged hospitalisation. Patients with CKD/No ESRD (1.13 (1.10-1.15), p < 0.001) and ESRD (1.34 (1.26-1.41), p < 0.001) were also at higher odds of moderate-to-severe disability on discharge. Interaction terms between thrombolysis and the CKD/ESRD groups were not statistically significant (p > 0.01) for any outcome.

CONCLUSIONS

Renal dysfunction was independently associated with worse in-hospital outcomes in the acute phase of AIS. These associations were not influenced by the use of thrombolysis as an emergency treatment for AIS. CKD/ESRD should not represent sole contraindications to thrombolysis for AIS.

Influence of Estimated Glomerular Filtration Rate on Clinical Outcomes in Patients with Acute Ischemic Stroke Not Receiving Reperfusion Therapies

Background: We aimed to determine whether estimated glomerular filtration rate (eGFR) is an independent predictor of clinical outcomes in patients with acute ischemic stroke not treated with reperfusion therapy. Methods: A total of 1420 patients with acute ischemic stroke from a hospital-based stroke registry were included in this study. Patients managed with intravenous thrombolysis or endovascular reperfusion therapy were excluded. The included patients were categorized into five groups according to eGFR, as follows: ≥90, 60–89, 45–59, 30–44, and <30 mL/min/1.73 m². The effects of eGFR on functional outcome at discharge, in-hospital mortality, neurologic deterioration, and hemorrhagic transformation were evaluated using logistic regression analyses. Results: In univariable logistic regression analysis, reduced eGFR was associated with poor functional outcome at discharge (p < 0.001) and in-hospital mortality (p = 0.001), but not with neurologic deterioration and hemorrhagic transformation. However, no significant associations were observed between eGFR and any clinical outcomes in multivariable analysis after adjusting for clinical and laboratory variables. Conclusions: Reduced eGFR was associated with poor functional outcomes at discharge and in-hospital mortality but was not an independent predictor of short-term clinical outcomes in patients with acute ischemic stroke who did not undergo reperfusion therapy.

Association of chronic kidney disease with in-hospital outcomes of endovascular stroke interventions

BACKGROUND

Data on the differential impact of chronic kidney disease (CKD) on the outcomes of endovascular stroke interventions (ESI) for acute ischemic stroke (AIS) are limited.

METHODS

Adult patients who underwent ESI for AIS between October 1st, 2015 and September 30th, 2019, were identified in a national multicenter database. The primary endpoints were in-hospital mortality and poor functional outcomes. Secondary endpoints included intracranial hemorrhage, mechanical ventilation, pneumonia, myocardial infarction, blood transfusion, length of stay, and cost. A multilevel mixed-effects regression model was used to derive adjusted outcomes.

RESULTS

A total of 22,193 AIS patients who underwent ESI at 99 centers were included. Among those, 18,881 (85%) had no CKD, and 3312 (15%) had CKD. Patients with CKD were older and had a higher prevalence of key comorbidities. After multivariable risk adjustment, patients with CKD had significantly higher in-hospital mortality (Odds Ratio [OR] 1.55 [95% Confidence Interval] [CI] 1.40-1.73, p < 0.01), and poor functional outcomes (OR 1.38, 95%CI 1.26-1.50, p < 0.01). Major complications, including mechanical ventilation, pneumonia, blood transfusion, and myocardial infarction, were more common among CKD patients, who also had longer hospitalizations and accrued higher cost.

CONCLUSION

The presence of CKD in patients with AIS treated with ESI is an independent predictor of in-hospital mortality and poor functional outcomes at discharge.

Renal Dysfunction and In-Hospital Outcomes in Patients With Acute Ischemic Stroke After Intravenous Thrombolytic Therapy

Background

The impact of estimated glomerular filtration rate (eGFR) on clinical short‐term outcomes after stroke thrombolysis with tissue plasminogen activator remains controversial.

Methods and Results

We analyzed 18 320 ischemic stroke patients who received intravenous tissue plasminogen activator at participating hospitals in the Chinese Stroke Center Alliance between June 2015 and November 2017. Multivariate logistic regression models were used to evaluate associations between eGFR (<45, 45–59, 60–89, and ≥90 mL/min per 1.73 m²) and in‐hospital mortality and symptomatic intracerebral hemorrhage, adjusting for patient and hospital characteristics and the hospital clustering effect. Of the 18 320 patients receiving tissue plasminogen activator, 601 (3.3%) had an eGFR <45, 625 (3.4%) had an eGFR 45 to 59, 3679 (20.1%) had an eGFR 60 to 89, and 13 415 (73.2%) had an eGFR ≥90. As compared with eGFR ≥90, eGFR values <45 (6.7% versus 0.9%, adjusted odds ratio, 3.59; 95% CI, 2.18–5.91), 45 to 59 (4.0% versus 0.9%, adjusted odds ratio, 2.00; 95% CI, 1.18–3.38), and 60 to 89 (2.5% versus 0.9%, adjusted odds ratio, 1.67; 95% CI, 1.20–2.34) were independently associated with increased odds of in‐hospital mortality. However, there was no statistically significant association between eGFR and symptomatic intracerebral hemorrhage.

Conclusions

eGFR was associated with an increased risk of in‐hospital mortality in acute ischemic stroke patients after treatment with tissue plasminogen activator. eGFR is an important predictor of poststroke short‐term death but not of symptomatic intracerebral hemorrhage.