Upload
others
View
0
Download
0
Embed Size (px)
Citation preview
5/18/2020
1
Stroke Care in Patients with CKDConsiderations in Acute Care
Michael J. Lyerly, MDUniversity of Alabama at Birmingham
Birmingham VAMC
Disclosures
• No Financial Disclosures relevant to thisProgram
• Salary support through NIH StrokeNet includingARCADIA/ARCADIA CSI
• I will be discussing off-label use of IV alteplasefor the treatment of acute ischemic stroke
DO NOT
COPY
5/18/2020
2
Outline
• The General Approach to an Acute Stroke Patient
• Acute Care for CKD Patients
• Thrombolytics
• Intra-arterial Therapies
• General Medical Management
The General Approach to an Acute Stroke Patient
DO NOT
COPY
5/18/2020
3
Why Does Stroke Matter?
• 800,000 new strokes each year
• 200,000 recurrent strokes each year
• 5th leading cause of death in the US
• An American has a stroke every 40 seconds and someone dies from a stroke every 4 minutes
• Up to 30% of survivors have significant long term disability
Virani et al. Circulation. 2020.
The Stroke Chain of Survival
– Detection: Patient or bystander recognition
– Dispatch: Activation of 9-1-1 and priority EMS dispatch
– Delivery: Prompt triage and transport to the most appropriate stroke hospital and prehospital notification
– Door: Immediate ED triage to a high acuity area
– Data: Prompt ED evaluation, stroke team activation, laboratory studies and brain imaging
– Decision: Diagnosis and determination of most appropriate therapy; Discussion with patient and family
– Drug: Administration of appropriate drugs or other interventions
– Disposition: Timely admission to a stroke unit
DO NOT
COPY
5/18/2020
4
Key Components of Emergency Stroke Care
• Ensure Medical Stability • Keep the patient NPO• Focused History and Examination
– Last Known Well Time
– Symptoms and Progression
– Medical History and Medications
• Laboratory Studies– CBC, CMP, Coagulation Studies, Glucose
• Imaging
CT Head CT Angiography CT Perfusion
Acute Stroke Therapies
• Intra-arterial Revascularization
• Thrombolytics
• Supportive Medical CareDO NOT
COPY
5/18/2020
5
Acute Care for CKD Patients
CKD in Patients Presenting with Acute Stroke
• Despite improvements in care and survival of patients with cardiovascular disease, patients with CKD, particularly those on dialysis, seem to have worse cardiovascular outcomes.
• In general, the neurologic manifestations of stroke in CKD patients do not differ from the general population.
• Given that CKD patients may harbor more advanced vascular disease, these patients may have more advanced baseline cerebrovascular disease burden and reduced cognitive reserve– Pre-existing physical and neurologic disability
– Pre-existing cognitive deficits
– Hemodynamic effects from dialysis
• Up to 1 in 3 AIS patients have some form of renal dysfunction ( <60 ml/min)
Roberts et al. Am J Kidney Disease. 2011.Weiner et al. Sem Nephrology. 2015. Tamura et a. Neurology. 2012.Rowat et al. Int J Stroke. 2014. DO N
OT COPY
5/18/2020
6
Muntner et al. Neph Dial Trans. 2011.
Delays in Presentation and Diagnosis
• The CHOICE study (cohort of 165 ESRD patients) suggested prolonged initial symptom recognition and presentation– Median time from symptom onset to ED presentation
was > 8 hours
• Factors underlying this have not been described– Knowledge of stroke signs/symptoms?
– Influence of premorbid physical and cognitive deficits?
– Socioeconomic factors?
• Opportunity for educationSozio et al. Am J Kidney Disease. 2009.DO N
OT COPY
5/18/2020
7
Imaging Studies
• Protocols for CTA/CTP differ by institution– CTA: 70-130 ml
– CTP 40-80 ml
• Many institutions have struggled to determine how to implement CTA/CTP for widespread use in acute stroke patients
DO NOT
COPY
5/18/2020
8
• Many academic centers perform CTA/P without creatinine but this is not standard or generalizable to community hospitals
• Is this appropriate for all patients?– Endovascular ineligible patients?
– Low likelihood for Large Vessel Occlusion?
– Known CKD? Powers et al. Stroke. 2019.
Thrombolysis with Alteplase
DO NOT
COPY
5/18/2020
9
Alteplase
• Recombinant tissue plasminogen activator
• Serine Protease
• Additionally used for MI, PTE, clot thrombolysis
Cathflo.com
• Randomized, double-blind trial of IV alteplase vs. placebo given within 3 hours of symptoms onset
• At 90 days, patients treated with alteplase were more likely to have minimal or no disability (38 vs 21%)
– This benefit was sustained one year later.
• Symptomatic intracerebral hemorrhage (sICH) within 36 hours after onset occurred in 6.4% of patients treated with alteplase (0.6% in placebo)
DO NOT
COPY
5/18/2020
10
• Treatment with alteplase 3-4.5 hours from symptom onset (821 pts)
• More favorable outcomes (modified Rankin Scale) at 90 days in the alteplase group (52% vs 45%, OR 1.34)
• Higher rates of symptomatic hemorrhage in the alteplasegroup (2.4% vs 0.2%); however, mortality did not differ– Hemorrhage rate was 7.9% using the NINDS definition
Alteplase in Practice
• Based on the NINDS trial, alteplase is approved for the treatment of stroke in the US up to 3 hours from symptom onset
• Alteplaseis approved up to 4.5 hours in Europe-The FDA evaluated this data but elected to not extend the approved window in the US
• Only 5-8% of patients receive alteplaseDO NOT
COPY
5/18/2020
11
Alteplase in CKD Patients with Acute Stroke
• CKD patients have generally not been excluded from acute stroke trials. Enrollment of patients on dialysis is very low which prohibits drawing meaningful conclusions.
• CKD patients are less likely to receive guideline concordant acute stroke care
• There is no dose adjustment based on renal function
Ovbiegele et al. Circ Cardiovasc QualOutcomes. 2014.
What about Outcomes?• There is some discrepancy among studies about
outcomes • A meta-analysis of 7 studies (7100 patients) found
increased symptomatic intracerebral hemorrhage (OR 1.56) and mortality (OR 1.7) among CKD patients treated with alteplase
• Among 44,410 alteplase treated patients in the GWTG registry:– 15,191 carried a CKD diagnosis– Higher unadjusted odds of sICH but this was attenuated by age,
hospital characteristics and risk factors– 22% higher odds of in-hospital mortality– 13% higher odds of unfavorable discharge functional status
Ovbiegele et al. Circ Cardiovasc QualOutcomes. 2014.Jung et al. J Neural Sci. 2015.DO N
OT COPY
5/18/2020
12
Alteplase in Dialysis Patients
• Very little data• Alteplase guidelines cite use of heparin within 48
hours with elevation in PTT as a contraindication– Is PTT a good marker here?
– K/DOQI guidelines (2005) suggest that this contraindication was not mean to apply to dialysis patients and advise considering each patient on a case by case basis
• A study of 1000 dialysis patients receving alteplasedid not find higher hemorrhage rates although in-hospital mortality was higher.
• There is still reluctance among stroke specialists…K/DOQI Workgroup, 2005.Tariq et al. JSCVD. 2013.Palacio et al. Clin Ja Am Soc Nephrol. 2011.
Alteplase in CKD Patient
• In patients who are treated with alteplase, the presence of CKD is likely associated with higher rates of hemorrhage and worse functional outcomes (observational data)
• In general, CKD should not be viewed as a contraindication to treatment
DO NOT
COPY
5/18/2020
13
Intra-arterial Therapies
Stroke Care Changed in 2015…
DO NOT
COPY
5/18/2020
14
And Again in 2018…
DO NOT
COPY
5/18/2020
15
DO NOT
COPY
5/18/2020
16
What do the Guidelines Say?
• AHA guidelines recommend non-invasive vessel imaging for patients with suspected large vessel occlusion (IA recommendation)
• It is reasonable to proceed with CTA before obtaining a serum creatinine concentration for those without history of renal impairment (IIB recommendation)
Powers et al. Stroke. 2019.
Putting this into Practice-Under 6 Hours
• Most patients will still get a CTA
• Utility of CTP is less defined
• There is still a lot of information to be gained about endovascular suitability from the non-contrasted CT scan– Hyperdense Vessels– Early Ischemic
Changes/ASPECTSDO NOT
COPY
5/18/2020
17
Putting this into Practice-6-24 hours
• Patient selection is driven by the clinical exam first and foremost– NIH Stroke Scale
– Symptoms suggestive of large territory/cortical involvement
• Multimodal imaging including perfusion studies are necessary but only in the appropriate clinical setting
Considerations in CKD patients
• Is a CTA/CTP necessary?
• Renal Protection Measures– Fewer contrast runs
– Lower dose contrast
• Close hemodynamic monitoring during and following the procedure
DO NOT
COPY
5/18/2020
18
Outcomes in CKD Patients
• In a study of 628 patients (15% with renal impairment), there was a 47% lower likelihood of a good functional outcome
• A second recent study of 378 patients (31% CKD), similarly found a 46% lower likelihood of good functional outcome. – Mortality was also increased in CKD patients (OR 2.19)
– No difference on hemorrhagic complications
– The incidence of contrast associated AKI has been reported to be ~3%
Sutherland et al. JSCVD. 2020.Xiao et al. Neurology, 2019. Dipose et al. Stroke. 2019.
Closing Thoughts
• CKD is common in patients presenting with acute stroke– Presenting symptoms and patterns may differ
• Increasingly, contrasted studies are being used in acute management
• Outcomes following alteplase and endovascular therapy differ between CKD and non-CKD patients
• CKD is should not preclude patients from acute treatments but may help guide prognostication and inform shared decision makingDO N
OT COPY