Hsieh Cheng-Yang, Lin Huey-Juan, Sung Sheng-Feng, Hsieh Han-Chieh, Lai Edward Chia-Cheng, Chen Chih-Hung
Department of Neurology, Tainan Sin Lau Hospital, Tainan, Taiwan, ROC.
Cerebrovasc Dis. 2014;37(1):51-6. doi: 10.1159/000356348. Epub 2013 Dec 21.
Renal dysfunction is a prevalent comorbidity in acute stroke patients requiring thrombolytic therapy. Reports studying the relationship between renal dysfunction and risk of postthrombolytic symptomatic intracerebral hemorrhage (SICH) are contradictory. We aimed to compare the safety and effectiveness of thrombolytic therapy in acute stroke patients with and without renal dysfunction.
Based on the prospective stroke registries of 4 hospitals in Taiwan from 2007-2012, we identified acute stroke patients who received thrombolytic therapy. Clinically significant renal dysfunction was defined as an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m(2). Renal dysfunction was further defined as stage 3 (30 ≤ eGFR < 60 ml/min/ 1.73 m(2)), stage 4 (15 ≤ eGFR < 30 ml/min/1.73 m(2)) and stage 5 (<15 ml/min/1.73 m(2)). The rates of SICH and poor outcome (defined as modified Rankin scale score ≥4) at 3 months after thrombolytic therapy were compared in patients with and without renal dysfunction. SICH was determined according to the definition of the National Institute of Neurological Disorders and Stroke. Multivariable logistic regression was used to determine the effect of renal dysfunction on outcome. Patients with different stages of renal dysfunction were further analyzed to determine the effect of disease severity on outcome.
Of the 657 stroke patients with thrombolysis, 239 (36%) had renal dysfunction, including 212 patients in stage 3, 17 patients in stage 4 and 10 patients in stage 5 of renal dysfunction. Patients with renal dysfunction were older and more likely to have hypertension, ischemic heart disease, congestive heart failure and prior antiplatelet use than those without. There were no differences in SICH (8 vs. 7%, p = 0.580) and poor outcome (41 vs. 39%, p = 0.758) between patients with and without renal dysfunction. After multivariable analysis, renal dysfunction was not associated with SICH (odds ratio: 1.03, 95% confidence interval: 0.55-1.92) and poor outcome. Pretreatment stroke severity was the only factor significantly associated with both SICH and poor outcome at 3 months. When stratifying renal dysfunction into stage 3 and stage ≥4, there was no significant increase in SICH as the severity of renal dysfunction increased after multivariable adjustment.
Renal dysfunction did not increase the risk of SICH and poor outcome at 3 months after stroke thrombolysis. Further study comparing directly the risk and benefit of thrombolytic therapy versus no therapy in stroke patients with renal dysfunction is warranted.
肾功能不全是需要溶栓治疗的急性卒中患者中普遍存在的合并症。关于肾功能不全与溶栓后症状性脑出血（SICH）风险之间关系的研究报告相互矛盾。我们旨在比较急性卒中伴和不伴肾功能不全患者溶栓治疗的安全性和有效性。
基于台湾4家医院2007 - 2012年的前瞻性卒中登记，我们确定了接受溶栓治疗的急性卒中患者。临床上显著的肾功能不全定义为估计肾小球滤过率（eGFR）<60 ml/min/1.73 m²。肾功能不全进一步分为3期（30≤eGFR<60 ml/min/1.73 m²）、4期（15≤eGFR<30 ml/min/1.73 m²）和5期（<15 ml/min/1.73 m²）。比较有和没有肾功能不全患者溶栓治疗后3个月时SICH发生率和不良结局（定义为改良Rankin量表评分≥4）。根据美国国立神经疾病和中风研究所的定义确定SICH。采用多变量逻辑回归确定肾功能不全对结局的影响。对不同肾功能不全分期的患者进一步分析，以确定疾病严重程度对结局的影响。
在657例接受溶栓治疗的卒中患者中，239例（36%）存在肾功能不全，其中212例为3期肾功能不全，17例为4期，10例为5期。肾功能不全患者比无肾功能不全患者年龄更大，更可能患有高血压、缺血性心脏病、充血性心力衰竭和既往使用过抗血小板药物。有和没有肾功能不全的患者之间SICH发生率（8%对7%，p = 0.580）和不良结局发生率（41%对39%，p = 0.758）没有差异。多变量分析后，肾功能不全与SICH（比值比：1.03，95%置信区间：0.55 - 1.92）和不良结局无关。溶栓前的卒中严重程度是与3个月时SICH和不良结局均显著相关的唯一因素。当将肾功能不全分为3期和≥4期时，多变量调整后，随着肾功能不全严重程度增加，SICH发生率没有显著增加。
肾功能不全并未增加卒中溶栓后3个月时SICH和不良结局的风险。有必要进一步直接比较肾功能不全的卒中患者溶栓治疗与不治疗的风险和获益。
