Severe Renal Impairment Is Associated With Symptomatic Intracerebral Hemorrhage After Thrombolysis for Ischemic Stroke

Abstract

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.)

Is Renal Dysfunction Associated with Adverse Stroke Outcome after Thrombolytic Therapy?

“…We compared our results with those of the previous 6 related studies (table 4) [8,9,10,11,21,22]. Notably in the largest previous study [22], severe renal impairment (eGFR <30 ml/min/1.73 m 2 ) was independently associated with SICH (odds ratio, OR: 3.75; 95% confidence interval, CI: 1.44-9.80). In another large Japanese cohort, renal dysfunction was an independent risk factor for SICH, poor outcome and mortality at 3 months [11].…”

Influence of Renal Function on Treatment Results after Stroke Thrombectomy

“…An explanation of this result remains speculative, but we suppose that the monocenter approach and the sample size of our investigation may contribute to this finding. Data on whether RD represents an independent risk factor for ICH after rtPA treatment are highly incongruent, as some studies found a significant association while others did not [3,5,6,7,8,9,30,31]. However, there is some evidence that microbleeds are associated with an elevated risk of ICH after rtPA treatment [32] and this brain pathology is particularly common in patients with RD [33].…”

Prognostic Biomarkers in Patients with Ischemic Stroke Who Received Thrombolytic Therapy

“…Furthermore GFR < 30 mL/min was strongly associated with a poor outcome. In several studies increased risk of hemorrhagic complications was observed after received thrombolytic therapy in patients with renal dysfunction [10,12,16,20]. However Power A. et al did not found any significant association between renal impairment and higher rate of sICH (symptomatic intracerebral hemorrhage).…”

“…In this study GFR level lower than 61.65 mL/min/1.73m 2 before treatment was determined as a poor prognostic biomarker especially in patients with severe stroke (NIHSS > 14). Previous reports on the relationship between renal dysfunction and the risk of a poor outcome were conflicting [10][11][12][13][14][15][16][17][18][19][20]. Among these studies, a GFR level lower than 60 mL/min mostly was used as the definition of renal dysfunction.…”