Serum creatinine may indicate risk of symptomatic intracranial hemorrhage after intravenous tissue plasminogen activator (IV tPA).
Serum creatinine may indicate risk of symptomatic intracranial hemorrhage after intravenous tissue plasminogen activator (IV tPA).
复制标题
DOI：
10.1097/md.0000000000000006
复制
发表时间：
2013-11
期刊：
影响因子：
1.6
通讯作者：
Llinas RH
中科院分区：
文献类型：
--
作者：
Marsh EB;Gottesman RF;Hillis AE;Urrutia VC;Llinas RH
症状性颅内出血(SICH)是静脉注射组织型纤溶酶原激活剂(IVtPA)治疗急性缺血性卒中后的已知并发症。SICH会导致高死亡率或长期伤残率。我们预测其发生的能力在临床决策和向家庭提供咨询时非常重要。最初的国家神经疾病和中风研究所(NINDS)的研究人员开发了一份关于静脉注射tPA的相对禁忌症的清单，旨在降低随后发生SICH的风险。到目前为止，肾损害的影响还没有得到很好的研究。在目前的研究中，我们评估了肾损害和tPA后颅内出血(ICH)之间的潜在联系。记录224例患者入院时的血肌酐和估计肾小球滤过率(EGFR)，这些患者在发病4.5小时内出现症状，并根据NINDS标准接受静脉注射tPA治疗。在tPA后1天进行神经成像，并对神经状态的任何变化进行脑出血评估。影像由一名委员会认证的神经放射科医生和两名视而不见患者神经状态的审查员进行了出血的回顾性评估。回顾医疗记录，寻找神经功能下降的证据，表明有“症状性”出血。SICH被定义为主观的临床恶化(由初级神经科团队记录)和神经成像上被认为是最可能的原因的出血。肾损害的评估方法包括：1)连续的肌酐；2)任何由肌酐造成的肾损害(血肌酐和GT；1.0 mg/dL)；3)持续的EGFR；以及4)由EGFR造成的任何肾损害(EGFR和每1.73平方米60毫升/分钟)。使用学生配对t检验、Fisher精确检验和多变量Logistic回归(根据人口统计学和血管危险因素进行调整)来评估肾损害和脑出血之间的关系。在224名患者中，57名(25%)在神经影像上有一些出血的证据。大多数患者没有症状。肾损害(由血肌酐和GT1.0 mg/dL定义)与有症状和无症状的颅内出血无关(p=0.359)；然而，当肌酐为1.0 mg/dL时，发生SICH的几率调整后增加5.5倍(95%可信区间，1.08-28.39)，血清肌酐升高的患者发生SICH的频率为10.6%(12/113)，而肾功能正常的患者发生SICH的频率为1.8%(2/111p=0.010)。我们的研究表明，肾损害与静脉注射tPA后发生SICH的风险较高有关。由于静脉注射tPA是治疗急性缺血性卒中的一种重要而有效的方法，因此需要一项多中心研究来确定这项回顾性研究中肾功能障碍与SICH相关的观察结果是否适用于一项更大规模的前瞻性试验。
Symptomatic intracranial hemorrhage (sICH) is a known complication following administration of intravenous tissue plasminogen activator (IV tPA) for acute ischemic stroke. sICH results in high rates of death or long-term disability. Our ability to predict its occurrence is important in clinical decision making and when counseling families. The initial National Institute of Neurological Disorders and Stroke (NINDS) investigators developed a list of relative contraindications to IV tPA meant to decrease the risk of subsequent sICH. To date, the impact of renal impairment has not been well studied. In the current study we evaluate the potential association between renal impairment and post-tPA intracranial hemorrhage (ICH). Admission serum creatinine and estimated glomerular filtration rate (eGFR) were recorded in 224 patients presenting within 4.5 hours from symptom onset and treated with IV tPA based on NINDS criteria. Neuroimaging was obtained 1 day post-tPA and for any change in neurologic status to evaluate for ICH. Images were retrospectively evaluated for hemorrhage by a board-certified neuroradiologist and 2 reviewers blinded to the patient’s neurologic status. Medical records were reviewed retrospectively for evidence of neurologic decline indicating a “symptomatic” hemorrhage. sICH was defined as subjective clinical deterioration (documented by the primary neurology team) and hemorrhage on neuroimaging that was felt to be the most likely cause. Renal impairment was evaluated using both serum creatinine and eGFR in a number of ways: 1) continuous creatinine; 2) any renal impairment by creatinine (serum creatinine >1.0 mg/dL); 3) continuous eGFR; and 4) any renal impairment by eGFR (eGFR <60 mL/min per 1.73 m2). Student paired t tests, Fisher exact tests, and multivariable logistic regression (adjusted for demographics and vascular risk factors) were used to evaluate the relationship between renal impairment and ICH. Fifty-seven (25%) of the 224 patients had some evidence of hemorrhage on neuroimaging. The majority of patients were asymptomatic. Renal impairment (defined by serum creatinine >1.0 mg/dL) was not associated with combined symptomatic and asymptomatic intracranial bleeding (p = 0.359); however, there was an adjusted 5.5-fold increased odds of sICH when creatinine was >1.0 mg/dL (95% confidence interval, 1.08–28.39), and the frequency of sICH for patients with elevated serum creatinine was 10.6% (12/113), versus 1.8% (2/111) in those with normal renal function (p = 0.010). Our study suggests that renal impairment is associated with higher risk of sICH after administration of IV tPA. As IV tPA is an important and effective treatment for acute ischemic stroke, a multicenter study is needed to determine whether the observation that renal dysfunction is associated with sICH from this retrospective study holds true in a larger prospective trial.