The impact of chronic kidney disease on prognosis in acute stroke: unraveling the pathophysiology and clinical complexity for optimal management

Kruthajn Rajesh^{1

2}, Kevin J Spring^{3

4

5}, Ivica Smokovski⁶, Vedant Upmanyue^{1

2}, Man Mohan Mehndiratta⁷, Giovanni F M Strippoli^{8

9}, Roy G Beran^{1

2

3

5

10

11}, Sonu M M Bhaskar^{12

13

14

15

16}

Affiliations

¹ Global Health Neurology Lab, Sydney, NSW, 2150, Australia.
² UNSW Medicine and Health, University of New South Wales (UNSW), South West Sydney Clinical Campuses, Sydney, NSW 2F170, Australia.
³ NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW, 2170, Australia.
⁴ Medical Oncology Group, Ingham Institute for Applied Medical Research, Sydney, NSW, 2751, Australia.
⁵ School of Medicine, Western Sydney University, Sydney, NSW, 2000, Australia.
⁶ Diabetes and Metabolic Disorders Skopje, Faculty of Medical Sciences, University Clinic of Endocrinology, The Goce Delčev University of Štip, Štip, North Macedonia.
⁷ Department of Neurology, BLK Super Speciality Hospital, New Delhi, India.
⁸ Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.
⁹ Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari "Aldo Moro", 70124, Bari, Italy.
¹⁰ Griffith Health, School of Medicine and Dentistry, Griffith University, Southport, QLD, 4215, Australia.
¹¹ Department of Neurology & Neurophysiology, Liverpool Hospital and South West Sydney Local Health District, Liverpool, NSW, 2170, Australia.
¹² Global Health Neurology Lab, Sydney, NSW, 2150, Australia. Sonu.Bhaskar@globalhealthneurolab.org.
¹³ UNSW Medicine and Health, University of New South Wales (UNSW), South West Sydney Clinical Campuses, Sydney, NSW 2F170, Australia. Sonu.Bhaskar@globalhealthneurolab.org.
¹⁴ NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW, 2170, Australia. Sonu.Bhaskar@globalhealthneurolab.org.
¹⁵ Department of Neurology & Neurophysiology, Liverpool Hospital and South West Sydney Local Health District, Liverpool, NSW, 2170, Australia. Sonu.Bhaskar@globalhealthneurolab.org.
¹⁶ National Cerebral and Cardiovascular Center (NCVC), Department of Neurology, Division of Cerebrovascular Medicine and Neurology, Suita, Osaka, 564-8565, Japan. Sonu.Bhaskar@globalhealthneurolab.org.

PMID: 39627467
DOI: 10.1007/s10157-024-02556-w

Review

The impact of chronic kidney disease on prognosis in acute stroke: unraveling the pathophysiology and clinical complexity for optimal management

Kruthajn Rajesh et al. Clin Exp Nephrol. 2025 Feb.

. 2025 Feb;29(2):149-172.

doi: 10.1007/s10157-024-02556-w. Epub 2024 Dec 3.

Authors

Affiliations

¹ Global Health Neurology Lab, Sydney, NSW, 2150, Australia.
² UNSW Medicine and Health, University of New South Wales (UNSW), South West Sydney Clinical Campuses, Sydney, NSW 2F170, Australia.
³ NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW, 2170, Australia.
⁴ Medical Oncology Group, Ingham Institute for Applied Medical Research, Sydney, NSW, 2751, Australia.
⁵ School of Medicine, Western Sydney University, Sydney, NSW, 2000, Australia.
⁶ Diabetes and Metabolic Disorders Skopje, Faculty of Medical Sciences, University Clinic of Endocrinology, The Goce Delčev University of Štip, Štip, North Macedonia.
⁷ Department of Neurology, BLK Super Speciality Hospital, New Delhi, India.
⁸ Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.
⁹ Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari "Aldo Moro", 70124, Bari, Italy.
¹⁰ Griffith Health, School of Medicine and Dentistry, Griffith University, Southport, QLD, 4215, Australia.
¹¹ Department of Neurology & Neurophysiology, Liverpool Hospital and South West Sydney Local Health District, Liverpool, NSW, 2170, Australia.
¹² Global Health Neurology Lab, Sydney, NSW, 2150, Australia. Sonu.Bhaskar@globalhealthneurolab.org.
¹³ UNSW Medicine and Health, University of New South Wales (UNSW), South West Sydney Clinical Campuses, Sydney, NSW 2F170, Australia. Sonu.Bhaskar@globalhealthneurolab.org.
¹⁴ NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW, 2170, Australia. Sonu.Bhaskar@globalhealthneurolab.org.
¹⁵ Department of Neurology & Neurophysiology, Liverpool Hospital and South West Sydney Local Health District, Liverpool, NSW, 2170, Australia. Sonu.Bhaskar@globalhealthneurolab.org.
¹⁶ National Cerebral and Cardiovascular Center (NCVC), Department of Neurology, Division of Cerebrovascular Medicine and Neurology, Suita, Osaka, 564-8565, Japan. Sonu.Bhaskar@globalhealthneurolab.org.

PMID: 39627467
DOI: 10.1007/s10157-024-02556-w

Abstract

Background: Chronic kidney disease (CKD) significantly increases stroke risk and severity, posing challenges in both acute management and long-term outcomes. CKD contributes to cerebrovascular pathology through systemic inflammation, oxidative stress, endothelial dysfunction, vascular calcification, impaired cerebral autoregulation, and a prothrombotic state, all of which exacerbate stroke risk and outcomes.

Methods: This review synthesizes evidence from peer-reviewed literature to elucidate the pathophysiological mechanisms linking CKD and stroke. It evaluates the efficacy and safety of acute reperfusion therapies-intravenous thrombolysis and endovascular thrombectomy-in CKD patients with acute ischemic stroke. Considerations, such as renal function, drug dosage adjustments, and the risk of contrast-induced nephropathy, are critically analyzed. Evidence-based recommendations and research priorities are drawn from an analysis of current practices and existing knowledge gaps.

Results: CKD influences stroke outcomes through systemic and local pathophysiological changes, necessitating tailored therapeutic approaches. Reperfusion therapies are effective in CKD patients but require careful monitoring of renal function to mitigate risks, such as contrast-induced nephropathy and thrombolytic complications. The bidirectional relationship between stroke and CKD highlights the need for integrated management strategies to address both conditions. Early detection and optimized management of CKD significantly reduce stroke-related morbidity and mortality.

Conclusion: Optimizing stroke care in CKD patients requires a comprehensive understanding of their pathophysiology and clinical management challenges. This article provides evidence-based recommendations, emphasizing individualized treatment decisions and coordinated care. It underscores the importance of integrating renal considerations into stroke treatment protocols and highlights the need for future research to refine therapeutic strategies, address knowledge gaps, and consider tailored interventions to improve outcomes and quality of life for this high-risk population.

Keywords: Chronic kidney disease; Endovascular thrombectomy; Reperfusion therapy; Stroke; Thrombolysis.

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Conflict of interest statement

Declarations. Conflicts of interest: The authors declare that they have no conflict of interest. Ethics approval: All analyses were based on previously published studies; thus, no ethical approval and patient consent are required. Consent to participate: Not applicable. Consent to publish: Not applicable.

References

1. Kelly DM, Ademi Z, Doehner W, Lip GYH, Mark P, Toyoda K, et al. Chronic kidney disease and cerebrovascular disease: consensus and guidance from a KDIGO controversies conference. Stroke. 2021;52(7):e328–46. - DOI - PubMed
1. Feigin VL, Brainin M, Norrving B, Martins S, Sacco RL, Hacke W, et al. World stroke organization (WSO): global stroke fact sheet 2022. Int J Stroke. 2022;17(1):18–29. https://doi.org/10.1177/17474930211065917 . - DOI - PubMed
1. Lee M, Saver JL, Chang KH, Liao HW, Chang SC, Ovbiagele B. Low glomerular filtration rate and risk of stroke: meta-analysis. BMJ. 2010. https://doi.org/10.1136/bmj.c4249 . - DOI - PubMed - PMC
1. Nayak-Rao S, Shenoy MP. Stroke in patients with chronic kidney disease…: how do we approach and manage it? Ind J Nephrol. 2017;27(3):167–71. https://doi.org/10.4103/0971-4065.202405 . - DOI
1. Rajesh K, Spring K, Beran R, Bhaskar S. Chronic kidney disease prevalence and clinical outcomes in anterior circulation acute ischemic stroke patients with reperfusion therapy: a meta-analysis. Nephrology. 2023. https://doi.org/10.1111/nep.14251 . - DOI - PubMed

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The impact of chronic kidney disease on prognosis in acute stroke: unraveling the pathophysiology and clinical complexity for optimal management

Affiliations

The impact of chronic kidney disease on prognosis in acute stroke: unraveling the pathophysiology and clinical complexity for optimal management

Authors

Affiliations

Abstract

Conflict of interest statement

References

Publication types

MeSH terms

Grants and funding

LinkOut - more resources

Full Text Sources

Medical