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.

Pulmonary embolism (PE) is a common disease with an annual incidence rate ranging from 39–115 per 100,000 inhabitants. It is one of the leading causes of cardiovascular mortality in the USA and Europe. While the clinical presentation and severity may vary, it is a life-threatening condition in its most severe form, defined as high-risk or massive PE. Therapeutic options in high-risk PE are limited. Current guidelines recommend the use of systemic thrombolytic therapy as first-line therapy (Level Ib). However, this treatment has important drawbacks including bleeding complications, limited efficacy in patients with recurrent PE or cardiac arrest, and formal contraindications. In this context, the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in the management of high-risk PE has increased worldwide in the last decade. Strategies, including VA-ECMO as a stand-alone therapy or as a bridge to alternative reperfusion therapies, are associated with acceptable outcomes, especially if implemented before cardiac arrest. Nonetheless, the level of evidence supporting ECMO and alternative reperfusion therapies is low. The optimal management of high-risk PE patients will remain controversial until the realization of a prospective randomized trial comparing those cited strategies to systemic thrombolysis.

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