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Sustained Low-Efficiency Dialysis is Associated with Worsening Cerebral Edema and Outcomes in Intracerebral Hemorrhage

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Abstract

Background/Objectives

We postulated that renal replacement therapy (RRT) in ICH patients with advanced chronic kidney disease (CKD) is associated with increased frequency and size of perihematomal edema (PHE) expansion and worse patient outcomes.

Methods

The Get With the Guidelines-Stroke Registry was queried for all patients admitted with ICH (N = 1089). Secondary causes, brainstem ICH, and initial HV < 7 cc were excluded. We identified patients with advanced CKD with and without RRT following admission for ICH. ABC/2 formula was used to measure hematoma volume (HV) and PHE. Patient outcomes were 30-day mortality, 90-day modified Rankin Scale score, and discharge disposition. We used propensity scores and optimal matching to adjust for multiple covariates.

Results

At 48 h post-ICH, PHE expansion was a significant predictor of poor patient outcomes in our cohort. Patients with CKD who received sustained low-efficacy dialysis (SLED) treatment had larger 48 h PHE growth compared to both untreated CKD group (average treatment effect (ATE), 11.5; 95% CI, 4.9–18.1; p < 0.01) and all untreated patients (ATE, 7.43; 95% CI, 4.7–10.2; p < 0.01). Moreover, patients with RRT had significantly worse functional and mortality outcomes.

Conclusions

SLED treatment in ICH patients with CKD was associated with significant increase in rate and frequency of PHE expansion. Absolute increase in PHE during 48-h post-ICH was associated with increased mortality and worse functional outcomes. Further prospective and multicenter evaluation is needed to differentiate the effects of RRT on hematoma dynamics and patient outcomes from those attributed to CKD.

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Abbreviations

ICH:

Intracerebral hemorrhage

IVH:

Intraventricular hemorrhage

CKD:

Chronic kidney disease

RRT:

Renal replacement therapy

SLED:

Sustained low-efficiency dialysis

HV:

Hematoma volume

PHE:

Perihematomal edema

mRS:

Modified Rankin scale

ATE:

Average treatment effects

OR:

Odds ratio

CI:

Confidence interval

mGS:

Modified Graeb score

WOC:

Withdrawal of care

References

  1. Stats F. National chronic kidney disease fact sheet, 2017. Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2017.

    Google Scholar 

  2. Hoerger TJ, Simpson SA, Yarnoff BO, et al. The future burden of CKD in the United States: a simulation model for the CDC CKD Initiative. Am J Kidney Dis. 2015;65:403–11.

    Article  PubMed  Google Scholar 

  3. Murray CJ, Barber RM, Foreman KJ, et al. Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: quantifying the epidemiological transition. The Lancet. 2015;386:2145–91.

    Article  Google Scholar 

  4. Wang H, Naghavi M, Allen C, et al. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet. 2016;388:1459–544.

    Article  Google Scholar 

  5. Luyckx VA, Tonelli M, Stanifer JW. The global burden of kidney disease and the sustainable development goals. Bull World Health Organ. 2018;96:414.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Molshatzki N, Orion D, Tsabari R, et al. Chronic kidney disease in patients with acute intracerebral hemorrhage: association with large hematoma volume and poor outcome. Cerebrovasc Dis. 2011;31:271–7.

    Article  PubMed  Google Scholar 

  7. An SJ, Kim TJ, Yoon B-W. Epidemiology, risk factors, and clinical features of intracerebral hemorrhage: an update. J Stroke. 2017;19:3.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Caceres JA, Goldstein JN. Intracranial hemorrhage. Emerg Med Clin N Am. 2012;30:771.

    Article  Google Scholar 

  9. Huang BR, Lo YL, Chang CH, Chen TY. Testing the outcome score of spontaneous intracerebral haemorrhage in haemodialysis patients. Intern Med J. 2009;39:692–5.

    Article  PubMed  Google Scholar 

  10. Kelly D, Rothwell PM. Disentangling the multiple links between renal dysfunction and cerebrovascular disease. J Neurol Neurosurg Psychiatry. 2020;91:88–97.

    Article  PubMed  Google Scholar 

  11. Molnar AO, Bota SE, Garg AX, et al. The risk of major hemorrhage with CKD. J Am Soc Nephrol. 2016;27:2825–32.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Rabiner SF, Molinas F. The role of phenol and phenolic acids on the thrombocytopathy and defective platelet aggregation of patients with renal failure. Am J Med. 1970;49:346–51.

    Article  CAS  PubMed  Google Scholar 

  13. Di Minno G, Martinez J, McKean M-L, De La Rosa J, Burke JF, Murphy S. Platelet dysfunction in uremia. Multifaceted defect partially corrected by dialysis. Am J Med. 1985;79:552–9.

    Article  PubMed  Google Scholar 

  14. Remuzzi G, Livio M, Marchiaro G, Mecca GD, De Gaetano G. Bleeding in renal failure: altered platelet function in chronic uraemia only partially corrected by haemodialysis. Nephron. 1978;22:347–53.

    Article  CAS  PubMed  Google Scholar 

  15. Sakamoto N, Ishikawa E, Aoki K, Uemae Y, Komatsu Y, Matsumura A. Clinical outcomes of intracerebral hemorrhage in hemodialysis patients. World Neurosurg. 2014;81:538–42.

    Article  PubMed  Google Scholar 

  16. Kumar A, Cage A, Dhar R. Dialysis-induced worsening of cerebral edema in intracranial hemorrhage: a case series and clinical perspective. Neurocrit Care. 2015;22:283–7.

    Article  PubMed  Google Scholar 

  17. Tschoe C, Bushnell CD, Duncan PW, Alexander-Miller MA, Wolfe SQ. Neuroinflammation after intracerebral hemorrhage and potential therapeutic targets. J Stroke. 2020;22:29.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Urday S, Kimberly WT, Beslow LA, et al. Targeting secondary injury in intracerebral haemorrhage—perihaematomal oedema. Nat Rev Neurol. 2015;11:111.

    Article  PubMed  Google Scholar 

  19. Grunwald Z, Beslow LA, Urday S, et al. Perihematomal edema expansion rates and patient outcomes in deep and lobar intracerebral hemorrhage. Neurocrit Care. 2017;26:205–12.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Leasure AC, Qureshi AI, Murthy SB, et al. Intensive blood pressure reduction and perihematomal edema expansion in deep intracerebral hemorrhage. Stroke. 2019;50:2016–22.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Eknoyan G, Lameire N, Eckardt K, et al. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int. 2013;3:5–14.

    Article  Google Scholar 

  22. Nash DM, Przech S, Wald R, O’Reilly D. Systematic review and meta-analysis of renal replacement therapy modalities for acute kidney injury in the intensive care unit. J Crit Care. 2017;41:138–44.

    Article  PubMed  Google Scholar 

  23. Morgan TC, Dawson J, Spengler D, et al. The Modified Graeb Score: an enhanced tool for intraventricular hemorrhage measurement and prediction of functional outcome. Stroke. 2013;44:635–41.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Volbers B, Staykov D, Wagner I, et al. Semi-automatic volumetric assessment of perihemorrhagic edema with computed tomography. Eur J Neurol. 2011;18:1323–8.

    Article  PubMed  Google Scholar 

  25. Qureshi AI, Tuhrim S, Broderick JP, Batjer HH, Hondo H, Hanley DF. Spontaneous intracerebral hemorrhage. N Engl J Med. 2001;344:1450–60.

    Article  CAS  PubMed  Google Scholar 

  26. Ducruet AF, Hickman ZL, Zacharia BE, et al. Exacerbation of perihematomal edema and sterile meningitis with intraventricular administration of tissue plasminogen activator in patients with intracerebral hemorrhage. Neurosurgery. 2010;66:648–55.

    Article  PubMed  Google Scholar 

  27. Yang J, Arima H, Wu G, et al. Prognostic significance of perihematomal edema in acute intracerebral hemorrhage: pooled analysis from the intensive blood pressure reduction in acute cerebral hemorrhage trial studies. Stroke. 2015;46:1009–13.

    Article  PubMed  Google Scholar 

  28. Murthy SB, Moradiya Y, Dawson J, et al. Perihematomal edema and functional outcomes in intracerebral hemorrhage: influence of hematoma volume and location. Stroke. 2015;46:3088–92.

    Article  PubMed  Google Scholar 

  29. Mayer SA, Brun NC, Broderick J, et al. Safety and feasibility of recombinant factor VIIa for acute intracerebral hemorrhage. Stroke. 2005;36:74–9.

    Article  CAS  PubMed  Google Scholar 

  30. Broderick JP, Diringer MN, Hill MD, et al. Determinants of intracerebral hemorrhage growth: an exploratory analysis. Stroke. 2007;38:1072–5.

    Article  CAS  PubMed  Google Scholar 

  31. Yogendrakumar V, Ramsay T, Fergusson DA, et al. Redefining hematoma expansion with the inclusion of intraventricular hemorrhage growth. Stroke. 2020;51:1120–7.

    Article  PubMed  Google Scholar 

  32. Yogendrakumar V, Ramsay T, Fergusson D, et al. New and expanding ventricular hemorrhage predicts poor outcome in acute intracerebral hemorrhage. Neurology. 2019;93:e879–88.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Hansen BM, Morgan TC, Betz JF, et al. Intraventricular extension of supratentorial intracerebral hemorrhage: the modified graeb scale improves outcome prediction in lund stroke register. Neuroepidemiology. 2016;46:43–50.

    Article  PubMed  Google Scholar 

  34. Tseng H-P, Lin F-J, Chen P-T, et al. Derivation and validation of a discharge disposition predicting model after acute stroke. J Stroke Cerebrovasc Dis. 2015;24:1179–86.

    Article  PubMed  Google Scholar 

  35. Belagaje SR, Zander K, Thackeray L, Gupta R. Disposition to home or acute rehabilitation is associated with a favorable clinical outcome in the SENTIS trial. J Neurointerv Surg. 2015;7:322–5.

    Article  PubMed  Google Scholar 

  36. Broderick JP, Brott TG, Duldner JE, Tomsick T, Huster G. Volume of intracerebral haemorrhage. A powerful and easy-to-use predictor of 30-day mortality. Stroke. 1993;24:987–93.

    Article  CAS  PubMed  Google Scholar 

  37. Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psychol Bull. 1979;86:420.

    Article  CAS  PubMed  Google Scholar 

  38. Kim JK, Shin JJ, Park SK, Hwang YS, Kim TH, Shin HS. Prognostic factors and clinical outcomes of acute intracerebral hemorrhage in patients with chronic kidney disease. J Korean Neurosurg Soc. 2013;54:296.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Jung J-M, Kim HJ, Ahn H, et al. Chronic kidney disease and intravenous thrombolysis in acute stroke: a systematic review and meta-analysis. J Neurol Sci. 2015;358:345–50.

    Article  PubMed  Google Scholar 

  40. El Husseini N, Kaskar O, Goldstein LB. Chronic kidney disease and stroke. Adv Chronic Kidney Dis. 2014;21:500–8.

    Article  PubMed  Google Scholar 

  41. Ironside N, Chen C-J, Ding D, Mayer SA, Connolly ES Jr. Perihematomal edema after spontaneous intracerebral hemorrhage. Stroke. 2019;50:1626–33.

    Article  PubMed  Google Scholar 

  42. Urday S, Beslow LA, Dai F, et al. Rate of peri-hematomal edema expansion predicts outcome after intracerebral hemorrhage. Crit Care Med. 2016;44:790.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Lattanzi S, Cagnetti C, Provinciali L, Silvestrini M. Blood pressure variability and clinical outcome in patients with acute intracerebral hemorrhage. J Stroke Cerebrovasc Dis. 2015;24:1493–9.

    Article  PubMed  Google Scholar 

  44. Zang Y, Zhang C, Song Q, et al. Therapeutic effect of early intensive antihypertensive treatment on rebleeding and perihematomal edema in acute intracerebral hemorrhage. J Clin Hypertens. 2019;21:1325–31.

    Article  CAS  Google Scholar 

  45. O’Rourke MF, Safar ME. Relationship between aortic stiffening and microvascular disease in brain and kidney: cause and logic of therapy. Hypertension. 2005;46:200–4.

    Article  PubMed  CAS  Google Scholar 

  46. Sharma S, Waikar SS. Intradialytic hypotension in acute kidney injury requiring renal replacement therapy. In: Seminars in dialysis. Wiley; 2017. p. 553–8.

  47. Tolwani A. Continuous renal-replacement therapy for acute kidney injury. N Engl J Med. 2012;367:2505–14.

    Article  CAS  PubMed  Google Scholar 

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Acknowledgements

We thank Caleb Stewart, MD, for assistance with semiautomatic image processing, and Billie Hsieh, MD, for assistance with data collection in the early stages of this study.

Funding

Research reported in this publication is supported by the Ochsner Translational Medicine Research Initiative sponsored by the Ochsner Health (II), and the Ochsner Clinic Foundation (II).

Author information

Authors and Affiliations

  1. Tulane University School of Medicine, 1430 Tulane Ave, New Orleans, LA, 70112, USA

    Alireza Shirazian

  2. Ochsner Clinical School, Jefferson, LA, USA

    Andres F. Peralta-Cuervo & Maria P. Aguilera-Pena

  3. Ochsner Clinic Foundation, Jefferson, LA, USA

    Louis Cannizzaro

  4. University of South Alabama School of Medicine, Mobile, AL, USA

    Vi Tran

  5. Institute for Translational Research, Ochsner Medical Center, Jefferson, LA, USA

    Doan Nguyen

  6. Ochsner Clinical School, The University of Queensland, Jefferson, LA, USA

    Ifeanyi Iwuchukwu

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  1. Alireza Shirazian
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  7. Ifeanyi Iwuchukwu
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Contributions

Alireza Shirazian, MD, MS: Major role in acquisition, statistical analysis & interpretation of the data; drafted the manuscript for intellectual content. Andrés F. Peralta-Cuervo, MD: Major role in the acquisition of data and analysis. Maria P. Aguilera-Pena, MD: Major role in the acquisition of data and analysis. Louis Cannizzaro, MD: Major role in the acquisition of data and analysis. Vi Tran , MD: Major role in the acquisition of data and analysis. Doan Nguyen, PhD: Interpreted the data; revised the manuscript for intellectual content. Ifeanyi Iwuchukwu, MD: Conceptualized and designed the study; interpreted the data and revised the manuscript for intellectual content.

Corresponding author

Correspondence to Alireza Shirazian.

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None of the authors has anything to disclose.

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The Ochsner Health Institution Review Board approved the use of data obtained from humans in this study.

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Shirazian, A., Peralta-Cuervo, A.F., Aguilera-Pena, M.P. et al. Sustained Low-Efficiency Dialysis is Associated with Worsening Cerebral Edema and Outcomes in Intracerebral Hemorrhage. Neurocrit Care 35, 221–231 (2021). https://doi.org/10.1007/s12028-020-01155-3

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  • DOI: https://doi.org/10.1007/s12028-020-01155-3

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