IV thrombolysis and renal function (original) (raw)
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Renal function and outcome among stroke patients treated with IV thrombolysis
Neurology, 2008
Renal function has been shown to be a prognostic marker for cardiovascular events. 1 We performed a databank-based analysis to investigate the prognostic value of renal function regarding functional outcome, recurrent stroke, and symptomatic intracranial hemorrhage (SICH) in stroke patients treated with IV recombinant tissue plasminogen activator (rtPA). Methods. All consecutive stroke patients (n ϭ 196) treated with IV-rtPA (1998-2006) were included. IV-rtPA was used according to current guidelines. 2 Baseline variables were extracted from our prospectively ascertained thrombolysis database. 3 The ethics committee approved of our approach to ascertain and analyze data of all rtPA-treated stroke patients. Estimates of renal function included serumcreatinine levels and glomerular filtration rates (GFR). Creatinine was measured at admission. GFR was calculated applying the simplified Modification of Diet in Renal Disease (MDRD) formula. 4 Endpoints were good (modified Rankin scale [mRS] Յ2) vs poor outcome (mRS Ͼ2, including death [cause of immediate death based on information of treating physician]), recurrent ischemic stroke at 3 months (WHO criteria), and SICH (National Institute of Neurological Disorders and Stroke trial definition). All patients had CT or MR scan (72 hours) and additional scans in case of clinical deterioration. Univariate analyses regarding good vs poor outcome were performed for creatinine, GFR, and baseline variables using Fisher exact tests or t tests. Secondly, multiple logistic regression was performed with the mRS Ͼ2 as dependent variable and NIHSS, age, and glucose as independent variables. Third, we compared GFR Ͼ90 vs GFR Ͻ90 mL/min/1.73 m 2 4 with regard to baseline characteristics (demographic variables, NIHSS score, risk factors, CRP, glucose, Charlson Index of comorbidity), mRS, cause of death, recurrent stroke, and SICH.
Renal Impairment Reduces the Efficacy of Thrombolytic Therapy in Acute Ischemic Stroke
Cerebrovascular Diseases, 2013
to determine the association between demographic characteristics and comorbid factors of interest and outcomes. eGFR was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. Results: There was no significant difference in mean time to thrombolysis between the groups (221 8 66 vs. 220 8 70 min from symptom onset; p = 0.9). An eGFR ! 60 ml/min was independently associated with a statistically significant reduction of the therapeutic effect of alteplase at 24 h on multivariate regression [coefficient -2.3, 95% confidence interval (CI) -3.7 to -0.9; p = 0.002], and this persisted at 7 days (coefficient -3.5, 95% CI -5.3 to -1.7; p ! 0.001). On modeling eGFR as a continuous variable, every 10 ml/min decline in eGFR was associated with a 0.40 diminution in NIHSS score improvement with alteplase (95% CI 0.07-0.74; p = 0.02). Older age and a higher presenting NIHSS score were associated with a greater therapeutic effect (p = 0.04 and p ! 0.001, respectively). In-patient mortality was 5%, with no significant differences between groups. Renal impairment was not associated with a higher rate of ICH (6.2 vs. 6.7%; p = 0.9). Greater NIHSS score at presentation was the only factor associated with a greater risk of death (odds ratio 1.24, 95% CI 1.10-1.40; p ! 0.001) and ICH (odds ratio 1.12, 95% CI 1.03-1.23; p = 0.004). Conclusions: Our results suggest that renal impairment is associated with reduced efficacy of thrombolysis in acute ischemic Abstract Background: Renal impairment is a potent risk factor for stroke, which remains a leading cause of death and disability. Thrombolysis for acute ischemic stroke has transformed patient outcomes, although the safety and efficacy of this approach remain poorly characterized in patients with renal dysfunction, who manifest a higher risk of bleeding due to uremia. We therefore examined the impact of renal impairment on clinical outcomes with thrombolysis within the current 4.5-hour therapeutic window. Methods: This retrospective multicenter cohort study (2009-2011) examined 229 stroke patients receiving thrombolysis with alteplase (0.9 mg/kg; mean age 70 8 13 years; 59% male, 24% diabetic). Sixty-five patients had an estimated glomerular filtration rate (eGFR) ! 60 ml/min. The primary outcome was the improvement in National Institutes of Health Stroke Scale (NIHSS) score at 24 h. Secondary outcomes included the NIHSS score at 7 days, the incidence of symptomatic and asymptomatic intracranial hemorrhage (ICH), extracranial bleeding and death during the index hospitalization. Univariate and multivariate regression analyses were performed Cerebrovasc Dis 2013;35:45-52 46 stroke without any excess hemorrhagic complications. This may relate to diminished fibrinolysis in the uremic milieu or differences in infarct anatomy. Longer-term prospective studies are required to characterize and improve functional outcomes following stroke in a manifestly high-risk group.
Stroke, 2013
I ntravenous thrombolysis with recombinant tissue plasminogen activator (iv-tPA) is the only approved treatment for acute ischemic stroke. 1 However, iv-tPA increases the risk of symptomatic intracranial hemorrhage (sICH). 2 Recently, several risk scores have been proposed to assess the risk of sICH. These scores included age, sex, stroke severity quantified by the National Institutes of Health Stroke Scale (NIHSS), baseline blood sugar, early infarct signs, 3 systolic blood pressure, history of hypertension, body weight, onset-to-treatment time (OTT), and pretreatment with antiplatelet drugs. 4,5 Although renal impairment (RI) is common in patients with stroke, only a few studies investigated whether RI influences the risk of sICH. Patients with low glomerular filtration rate (GFR) are known to have endothelial and platelet dysfunction and are at risk for both thrombotic and hemorrhagic events. 5,6 In this study, we investigated the association between RI and prevalence of sICH in patients with stroke receiving iv-tPA. Methods Study Population All patients with stroke who received iv-tPA within 4.5 hours of symptom onset at our institution between January 2005 and August 2012 were included. Iv-tPA was administered according to European license. The register has been described in detail elsewhere. 7 Serum creatinine levels (mmol/L) were measured for each patient on admission. Renal function was assessed by estimated GFR using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula. 8 Patients on dialysis were excluded. GFR values were dealt with as (1) centered data (cGFR) to test for linear association, (2) centered and squared data (csGFR) to test for curvilinear association, and (3) dichotomized data. Categorization was according to International Classification of Diseases for RI: no RI (GFR ≥90 mL/min), mild RI (GFR=60-89 mL/min), moderate RI (GFR=30-59 mL/min), and severe RI (GFR <30 mL/min). For univariate comparisons, GFR was dichotomized at 90 mL/min (any RI) and 30 mL/min (severe RI). Sociodemographic data, vascular risk factors, laboratory data, medication, OTT, and NIHSS were collected from the medical records. Outcome measures were sICH defined according to the European Cooperative Acute Stroke Study (ECASS) criteria (any Background and Purpose-Patients with renal impairment (RI) have an increased risk of both thrombotic and hemorrhagic events. We aimed to clarify whether RI increases the risk of intracerebral hemorrhage (ICH) after intravenous thrombolysis with recombinant tissue plasminogen activator. Methods-Patients who received intravenous thrombolysis with recombinant tissue plasminogen activator within 4.5 hours of symptom onset were retrospectively analyzed. Creatinine levels on admission served to calculate glomerular filtration rate (GFR) to estimate RI according to International Classification of Diseases criteria. Effect of RI on symptomatic ICH (sICH) was assessed using dichotomized (GFR <90 and <30 mL/min) and continuous GFR (centered data to test for linear and centered and squared data to test for curvilinear association). Results-Of the 740 patients included, 83% had any RI (GFR <90 mL/min) and 5% had severe RI (GFR <30 mL/mL); 4.6% experienced sICH. Univariate comparisons revealed higher prevalence of sICH in patients with severe RI (P<0.01) but not with any RI. GFR as a continuous variable (centered and squared) was also associated with sICH (P=0.02), but GFR on its own was not. Severe RI and GFR (centered and squared) remained independently associated with sICH in multiple regression analyses. Conclusions-Severe RI (GFR <30 mL/min) is associated with sICH after intravenous thrombolysis with recombinant tissue plasminogen activator. The association is curvilinear. Severe RI must be taken into account when balancing the risk-benefit ratio of intravenous thrombolysis with recombinant tissue plasminogen activator. (Stroke. 2013;44:3217-3219.
Journal of the American Heart Association, 2019
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 m 2) and inhospital 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.
Renal dysfunction and 30-day mortality risk in patients with acute stroke
African Journal of Nephrology
interest in reduced glomerular filtration rate (GFR) as an independent non-traditional risk factor for CVD and CVD mortality has come to the fore [4,5]. Studies suggest that reduced GFR may be an independent risk factor for poor outcomes in patients with myocardial infarction and stroke [6-8]. Yohalom et al. [8], in a prospective study involving 821 Israeli adults with acute stroke, found that reduced GFR was a strong independent predictor of mortality and poor outcomes. Mortality was associated
Aim: Chronic kidney disease (CKD) is a risk factor for stroke and in-hospital mortality due to stroke. Stroke is highly prevalent in CKD patients. Our aim was to evaluate the impact of glomerular filtration rate in acute ischemic stroke (IS) patients after thrombolytic therapy. Methods: All patients who underwent thrombolytic therapy for acute IS in our Department between 2009 and 2012 were studied retrospectively. Age, co-morbidities, blood pressure, glycaemia, National Institutes of health Stroke Scale score were evaluated. Renal function was estimated by CKD-EPI equation. Three-month outcome (death, residual disability, intracranial hemorrhage) in patients with glomerular filtration rate (GFR) <60 ml/min/1.73m2 was compared to that of patients with GFR ≥ 60 ml/min/1.73 m2. Logistic regression analysis was used to determine which factor was independently associated with outcome. Results: Among 191 patients treated for acute IS, 74 had GFR<60 ml/min/1.73m2. They were older and had higher prevalence of hypertension than patients with normal filtration rate. We found no differences in 3-month death or poor outcome between the two groups. However, patients with impaired renal function had a significantly higher risk of hemorrhagic complication (OR = 2.5; 95% CI = 1.1-6.2, p<0.01). Conclusion: GFR<60 ml/min/1.73m2 significantly affects the risk of intracranial hemorrhage in stroke patients treated with thrombolytic therapy. Hence, subjects with reduced renal function eligible for intravenous thrombolysis could be informed about the increased ICH risk.
Estimated glomerular filtration rate and risk of survival in acute stroke
Journal of the Neurological Sciences, 2013
Objective: To assess the risk of survival in acute stroke using the MDRD equation derived estimated glomerular filtration rate. Design: A prospective observational cross-sectional study. Setting: Medical wards of a tertiary care hospital. Subjects: Eighty three acute stroke patients had GFR calculated within 48 hours of admission after basic data were captured. Outcome measures: Stroke outcome was defined as either discharged or still-in-care (survived) or all cause in-hospital death. GFR was estimated by the MDRD equation, stroke severity was assessed by the Canadian Neurological Scale (CNS). Data were compared between the GFR groups of < 60ml/min and ≥ 60ml/min. Relative risks (RR) and odds ratios (OR) for stroke outcomes (survival and death) were estimated between the GFR groups and the homogeneity of the odds ratios among the different layers of stroke severity (CNS < 6.5 and ≥ 6.5) was determined by Breslow-Day and Tarone's test. Matanel Hazensel and Cochran's tests were used to determine conditional independence and the common odds ratio with stroke severity as a layering variable. Results: No significant differences were found between the age and sex distribution of the two GFR groups. Serum urea and creatinine and CNS were significantly different between the GFR groups (p<0.001, <0.001, <0.001). RR of survival and death for the GFR groups-less than 60ml/min and above or equal to 60ml/min were (0.425 and 1.204) and (2.360 and 0.830). The OR of survival for GFR below 60ml/min compared to GFR above or equal to 60ml/min was 0.353. There was homogeneity across the two layers of stroke severity (CNS score less than 6.5 and above or equal to 6.5), p=0.612 and 0.612. Conclusion: Independent of stroke severity, GFR is a surrogate in the assessment of the risk of survival in acute stroke
Introduction: Stroke is considered the second leading cause of death globally. Chronic kidney disease (CKD) has been identified as a risk factor for stroke. However, little is known about the impact of renal dysfunction on early mortality following acute ischemic stroke. The aim of the current study was to evaluate the prevalence of renal dysfunction among acute ischemic stroke patients and its role on the early overall mortality. Patients and methods: This prospective cohort study included a total of 889 patients with first ever ischemic stroke who were hospitalized within 24 hours of symptoms onset. All patients were clinically evaluated to determine stroke risk factors. Stroke severity was assessed using National Institute of Health Stroke Scale (NIHSS) in the 1st day of admission. Baseline investigations were obtained within 24 hours of admission, including serum creatinine and estimated Glomerular Filtration Rate (eGFR) that was calculated from the equation of the Modification Diet for Renal Disease in ml/min/1.73m2. Patients were followed up for 30 days after admission or at least until death. Results: Of the 800 stroke patients who completed follow up during the study period, 242 (30.2%) had renal dysfunction, and 128 (16%) died within 30-days of stroke onset, whereas mortality was higher (19.8%) in patients with eGFR <60 ml/min/1.73m2 than in patients (14%) with eGFR ?60 ml/min/1.73m2. In multivariate analysis, 30–days mortality risk of stroke was higher in patients with eGFR< 60ml/min/1.73 m2 (HR= 1.7, 95% CI=1.4–2, P=0.002), stroke severity (HR= 1.5, 95% CI=1.3- 1.7, P=0.001), and presence of atrial fibrillation (HR= 1.4, 95% CI=1.1-1.7, P=0.007). Meanwhile, the odds of mortality risk increased by 1.7 for each 1 mg/dl increase in baseline serum creatinine. Conclusion: The prevalence of renal dysfunction in our cohort of acute ischemic stroke patients was high. Presence of baseline renal dysfunction was recorded as an independent predictor of early mortality in the setting of acute ischemic stroke beside other well-known prognostic factors.
Renal function is associated with 1-month and 1-year mortality in patients with ischemic stroke
Atherosclerosis, 2017
Renal dysfunction is a potent risk factor for cardiovascular diseases, including stroke. This study aimed to evaluate the impact of admission estimated glomerular filtration rate (eGFR) levels on short-term (1-month) and long-term (1-year) mortality in patients with acute ischemic stroke. From the Taiwan Stroke Registry data, we classified ischemic stroke patients, identified from April 2006 to December 2015, into 5 groups by eGFR at admission: ≥ 90, 60-89, 30-59, 15-29, and <15 mL/min/1.73 m2 or on dialysis. Risks of 1-month mortality and 1-year mortality after ischemic stroke were investigated by the eGFR level. Among 52,732 ischemic stroke patients, 1480 died within one month. The 1-month mortality rate was over 5-fold greater in patients with eGFR <15 mL/min/1.73 m2 or dialysis than in patients with eGFR ≥90 mL/min/1.73 m2 (2.88 versus 0.56 per 1000 person-days). The adjusted hazard ratio (HR) of 1-month mortality increased from 1.31 (95% CI = 1.08-1.59) for patients with ...
Ischaemic stroke – impact of renal dysfunction on in-hospital mortality
European Journal of Neurology, 2007
Renal dysfunction predicts mortality in patients with myocardial infarction but less is known about the impact of renal dysfunction on in-hospital mortality after ischaemic stroke. All 361 patients (185 men, 176 women; mean age 72.1 years) with ischaemic stroke and glomerular filtration rate (GFR) <90 ml/min/1.73 m 2 were followed-up. GFR was calculated according to abbreviated modification of diet in renal disease (MDRD) formula. Stroke severity was determined by National Institutes of Health Stroke Scale (NIHSS). The mean GFR was 61.5 ± 16.6 ml/min/1.73 m 2 . There were 49 (13.6%) in-hospital deaths. Patients who died had higher NIHSS (P ¼ 0.0001), were older (P ¼ 0.024), had lower GFR (P ¼ 0.028), higher hs-C-reactive protein (P ¼ 0.001) and lower albumin (P ¼ 0.048). No differences in presence of diabetes and hypertension, cholesterol (total, HDL and LDL), triglycerides and BMI between patients who died or survived were found. With univariate analysis association between in-hospital mortality and NIHSS (P ¼ 0.0001), GFR (P ¼ 0.041), total cholesterol (P ¼ 0.021) and LDL cholesterol (P ¼ 0.034) was found. With Cox multivariable regression analysis of risk factors, NIHSS (P ¼ 0.0001), GFR (P ¼ 0.018), total cholesterol (P ¼ 0.008) and LDL cholesterol (P ¼ 0.011) were only predictors of in-hospital mortality. In patients with ischaemic stroke, decreased GFR was associated with higher in-hospital mortality.