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

Objective To determine the association of chronic kidney disease (CKD) with the safety and efficacy of IV thrombolysis (IVT) among patients with acute ischemic stroke (AIS). Methods A 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 intracranial hemorrhage (ICH), in-hospital and 3-month mortality, 3-month favorable functional outcome (FFO; modified Rankin Scale [mRS] score 0-1), and 3-month functional independence (FI, mRS score 0-2). CKD was defined with estimated glomerular filtration rate (eGFR) ranging from mild (eGFR 60-89 mL/min) to moderate (eGFR 30-59 mL/min) to severe (eGFR 15-29 mL/min). Results We identified 20 studies comprising 60,486 patients with AIS treated with IVT. In unadjusted analyses, CKD was associated with sICH according to the National Institute of Neurological Disorders and Stroke (NINDS) (7 studies; odds ratio [OR] 1.41, 95% confidence interval [CI] 1.19-1.67) and European Cooperative Acute Stroke Study (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; OR(adj)1.34, 95% CI 1.01-1.79) and ECASS II (3 studies; OR(adj)2.08, 95% CI 1.27-3.43) definitions, any ICH (6 studies; OR(adj)1.41, 95% CI 1.01-1.97), in-hospital mortality (2 studies; OR(adj)1.19, 95% CI 1.09-1.30), and 3-month FFO (6 studies; OR(adj)0.80, 95% CI 0.70-0.92). Conclusions After adjustment for confounders in this pairwise meta-analysis, moderate to severe CKD is associated with increased risks of ICH and worse functional outcomes among patients with AIS treated with IVT.