急性缺血性卒中静脉溶栓治疗后的慢性肾脏病与出血并发症
Chronic kidney disease and bleeding complications after intravenous thrombolytic therapy for acute ischemic stroke.
作者信息
Ovbiagele Bruce, Smith Eric E, Schwamm Lee H, Grau-Sepulveda Maria V, Saver Jeffrey L, Bhatt Deepak L, Hernandez Adrian F, Peterson Eric D, Fonarow Gregg C
机构信息
From the Department of Neurosciences, Medical University of South Carolina, Charleston (B.O.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Canada (E.E.S.); Division of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Outcomes Research and Assessment Group, Duke Clinical Research Institute, Durham, NC (M.V.G.-S., A.F.H., E.D.P.); Stroke Center and Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; and Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.).
出版信息
Circ Cardiovasc Qual Outcomes. 2014 Nov;7(6):929-35. doi: 10.1161/CIRCOUTCOMES.114.001144. Epub 2014 Sep 23.
BACKGROUND
The safety of intravenous thrombolysis in ischemic stroke (IS) patients with chronic kidney disease (CKD) is uncertain. We assessed whether CKD is associated with bleeding complications after intravenous tissue-type plasminogen activator administration to patients with IS.
METHODS AND RESULTS
Data were analyzed from 44 410 patients with IS treated with intravenous tissue-type plasminogen activator in the Get With The Guidelines-Stroke Program. Glomerular filtration rate based on admission serum creatinine was categorized as dichotomous (presence of CKD as <60) or as distinct categories: normal (≥90), mild (≥60-<90), moderate (≥30-< 60), severe (≥15-<30), and kidney failure (<15 or dialysis). Primary outcomes evaluated were symptomatic intracranial hemorrhage and serious systemic hemorrhage; secondary outcomes were in-hospital mortality, independent functional status. There were 15 191 of 44 410 (34%) intravenous tissue-type plasminogen activator-treated IS patients with CKD. Presence of CKD (versus no CKD) was not associated with risk-adjusted symptomatic intracranial hemorrhage (adjusted odds ratio, 1.0; 95% confidence interval: 0.91-1.10) or serious systemic hemorrhage (adjusted odds ratio, 0.97; 95% confidence interval: 0.80-1.18) and did not significantly vary by kidney dysfunction stage for either of these primary end points in multivariable analyses. Compared with patients with normal kidney function, those with CKD were more likely to die in the hospital (adjusted odds ratio, 1.22; 95% confidence interval: 1.14-1.32) and have an unfavorable discharge functional status (adjusted odds ratio, 1.13; 95% CI: 1.07-1.19).
CONCLUSIONS
Presence of CKD among patients with IS treated with intravenous tissue-type plasminogen activator is associated with higher unadjusted odds of symptomatic intracranial hemorrhage or serious systemic hemorrhage, but this is explained by non-CKD related factors.
背景
慢性肾脏病（CKD）缺血性卒中（IS）患者静脉溶栓的安全性尚不确定。我们评估了CKD是否与IS患者静脉注射组织型纤溶酶原激活剂后的出血并发症相关。
方法与结果
对“遵循指南-卒中项目”中44410例接受静脉组织型纤溶酶原激活剂治疗的IS患者的数据进行分析。根据入院时血清肌酐计算的肾小球滤过率分为二分法（CKD为<60）或不同类别：正常（≥90）、轻度（≥60-<90）、中度（≥30-<60）、重度（≥15-<30）和肾衰竭（<15或透析）。评估的主要结局为症状性颅内出血和严重全身性出血；次要结局为住院死亡率、独立功能状态。44410例接受静脉组织型纤溶酶原激活剂治疗的IS患者中有15191例（34%）患有CKD。CKD的存在（与无CKD相比）与风险调整后的症状性颅内出血（调整比值比，1.0；95%置信区间：0.91-1.10）或严重全身性出血（调整比值比，0.97；95%置信区间：0.80-1.18）无关，在多变量分析中，这两个主要终点中的任何一个在不同肾功能不全阶段均无显著差异。与肾功能正常的患者相比，患有CKD的患者更有可能在医院死亡（调整比值比，1.22；95%置信区间：1.14-1.32）且出院时功能状态不佳（调整比值比，1.13；95%CI：1.07-1.19）。
结论
接受静脉组织型纤溶酶原激活剂治疗的IS患者中，CKD的存在与症状性颅内出血或严重全身性出血的未调整比值较高相关，但这可由非CKD相关因素解释。
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