Epidemiology, thrombolytic management, and outcomes of acute stroke among patients with chronic kidney disease: a systematic review and meta-analysis

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.

Intravenous thrombolysis in patients with chronic kidney disease: A systematic review and meta-analysis

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; OR_adj 1.34, 95% CI 1.01-1.79) and ECASS II (3 studies; OR_adj 2.08, 95% CI 1.27-3.43) definitions, any ICH (6 studies; OR_adj 1.41, 95% CI 1.01-1.97), in-hospital mortality (2 studies; OR_adj 1.19, 95% CI 1.09-1.30), and 3-month FFO (6 studies; OR_adj 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.