Intravenous thrombolysis in patients with chronic kidney disease: A systematic review and meta-analysis

Objective We sought to determine the association of chronic kidney disease (CKD) with the safety and efficacy of intravenous thrombolysis (IVT) among acute ischemic stroke (AIS) patients.

Methods Systematic review and pairwise meta-analysis of studies involving patients with CKD undergoing IVT for AIS were conducted to evaluate the following outcomes: symptomatic intracranial hemorrhage (sICH), asymptomatic and any ICH, in-hospital and 3-month mortality, 3-month favorable functional outcome (FFO, mRS 0-1) and 3-month functional independence (FI, mRS 0-2). CKD was defined using estimated glomerular filtration rate (eGFR) ranging from mild (eGFR: 60-89ml/min), moderate (eGFR: 30-59ml/min) and severe (eGFR: 15-29ml/min).

Results We identified 20 studies comprising 60,486 AIS patients treated with IVT. In unadjusted analyses, CKD was associated with sICH according to NINDS (7 studies; OR=1.41, 95%CI: 1.19–1.67) and ECASS-II (9 studies; OR=1.37, 95%CI: 1.01–1.85) definitions, any ICH (8 studies; OR=1.42, 95%CI: 1.18–1.70), 3-month mortality (9 studies; OR = 2.20, 95%CI: 1.72–2.81), 3-month FFO (8 studies; OR=0.58, 95%CI: 0.47–0.72) and 3-month FI (8 studies; OR=0.57, 95%CI: 0.46–0.71). In adjusted analyses, CKD was associated with sICH according to NINDS (4 studies; ORadj=1.34, 95%CI: 1.01–1.79) and ECASS-II (3 studies; ORadj=2.08, 95%CI 1.27–3.43) definitions, any ICH (6 studies; ORadj=1.41, 95%CI 1.01–1.97), in-hospital mortality (2 studies; ORadj =1.19; 95%CI, 1.09-1.30) and 3-month FFO (6 studies; ORadj=0.80, 95%CI 0.70–0.92).  

Conclusions After adjustment for confounders in this pairwise meta-analysis, moderate-severe CKD is associated with increased risks of intracranial hemorrhage and worse functional outcomes among AIS patients treated with IVT.