From the Department of Cerebrovascular Medicine (K.M., M.K., S.Y., J.K., A.I., K.T.) and Center for Cerebral and Cardiovascular Disease Information (M.N., Y.S., Y.I., Y.M.), National Cerebral and Cardiovascular Center, Suita, Osaka; Department of Neurology (K.S.), Saiseikai Fukuoka Hospital, Fukuoka; Shimane University School of Medicine (S.K.), Izumo; and Medical Corporation ISEIKAI (K.M.), Osaka, Japan.
Neurology. 2022 Apr 26;98(17):e1738-e1747. doi: 10.1212/WNL.0000000000200153. Epub 2022 Mar 8.
Chronic kidney disease is a worldwide public health problem that is recognized as an established risk factor for stroke. It remains unclear whether its distribution and clinical impact are consistent across ischemic stroke subtypes in patients with renal impairment. We examined whether renal impairment was associated with the proportion of each stroke subtype vs ischemic stroke overall and with functional outcomes after each stroke subtype.
Study participants were 10,392 adult patients with an acute stroke from the register of the Japan Stroke Data Bank, a hospital-based multicenter stroke registration database, between October 2016 and December 2019, whose baseline serum creatinine levels or a dipstick proteinuria result were available. All ischemic strokes were classified according to the Trial of Org 10172 in Acute Stroke Treatment criteria. Unfavorable functional outcome was defined as modified Rankin Scale (mRS) score 3-6 at discharge. Mixed effect logistic regression was used to determine the relationship between the outcomes and the estimated glomerular filtration rate (eGFR), eGFR strata (<45, 45-59, ≥60 mL/min/1.73 m), or dipstick proteinuria ≥1 adjusted for covariates.
Overall, 2,419 (23%) patients had eGFR 45-59 mL/min/1.73 m and 1,976 (19%) had eGFR <45 mL/min/1.73 m, including 185 patients (1.8%) receiving hemodialysis. Both eGFR 45-59 and eGFR <45 mL/min/1.73 m were associated with a higher proportion of cardioembolic stroke (odds ratio [OR], 1.21 [95% CI, 1.05-1.39] and 1.55 [1.34-1.79], respectively) and a lower proportion of small vessel occlusion (0.79 [0.69-0.90] and 0.68 [0.59-0.79], respectively). A similar association with the proportion of these 2 subtypes was proven in the analyses using decreased eGFR as continuous values. Both eGFR <45 mL/min/1.73 m and proteinuria were associated with unfavorable functional outcomes in patients with cardioembolic stroke (OR, 1.30 [95% CI, 1.01-1.69] and 3.18 [2.03-4.98], respectively) and small vessel occlusion (OR, 1.44 [1.01-2.07] and 2.08 [1.08-3.98], respectively).
Renal impairment contributes to the different distributions and clinical effects across specific stroke subtypes, particularly evident in cardioembolic stroke and small vessel occlusion. This possibly indicates shared mechanisms of susceptibility and potentially enhancing pathways.
慢性肾脏病是一个全球性的公共卫生问题，已被确认为中风的既定危险因素。目前尚不清楚其在肾功能损害的缺血性卒中患者中，分布和临床影响是否一致。我们研究了肾功能损害是否与各卒中亚型占缺血性卒中的比例以及各卒中亚型的功能结局有关。
本研究纳入了 2016 年 10 月至 2019 年 12 月期间，来自日本卒中数据库登记处的 10392 名急性卒中成年患者。该登记处是一个基于医院的多中心卒中登记数据库，患者的基线血清肌酐水平或尿蛋白试纸检测结果可用。所有缺血性卒均按照急性卒中治疗试验（Trial of Org 10172 in Acute Stroke Treatment）的标准进行分类。功能不良结局定义为出院时改良 Rankin 量表（mRS）评分 3-6 分。采用混合效应逻辑回归来确定结局与估算肾小球滤过率（eGFR）、eGFR 分层（＜45、45-59、≥60 mL/min/1.73 m）或尿蛋白试纸检测阳性（≥1）之间的关系，并对协变量进行调整。
总体而言，2419 名（23%）患者的 eGFR 为 45-59 mL/min/1.73 m，1976 名（19%）患者的 eGFR ＜45 mL/min/1.73 m，其中 185 名（1.8%）患者正在接受血液透析。eGFR 45-59 和 eGFR ＜45 mL/min/1.73 m 与更高的心源性栓塞性卒中比例（比值比[OR]，1.21 [95%可信区间，1.05-1.39]和 1.55 [1.34-1.79]）和更低的小血管闭塞比例（0.79 [0.69-0.90]和 0.68 [0.59-0.79]）相关。在使用连续 eGFR 值进行的分析中，也证明了与这两种亚型比例的类似相关性。eGFR ＜45 mL/min/1.73 m 和蛋白尿与心源性栓塞性卒中（OR，1.30 [95%可信区间，1.01-1.69]和 3.18 [2.03-4.98]）和小血管闭塞（OR，1.44 [1.01-2.07]和 2.08 [1.08-3.98]）的不良功能结局相关。
肾功能损害导致特定卒中亚型的分布和临床影响不同，在心源性栓塞性卒中和小血管闭塞中尤为明显。这可能表明存在易感性和潜在增强途径的共同机制。
