Chronic Kidney Disease in Ischemic Stroke Carlee Oakley

Chronic Kidney Disease in Ischemic Stroke Carlee Oakley University of Kansas Medical Center PVRM 868 Biomedical Informatics Driven Clinical Research 2017

Presentation Overview Ø Background Ø Hypotheses and Specific Aims Ø Materials and Methods Ø Results Ø Conclusions Ø Limitations Ø Future Directions

Ischemic Stroke • A stroke occurs if the blood flow to a portion of the brain is blocked. Without oxygen, brain cells start to die after a few minutes. Symptoms then occur in the parts of the body that these brain cells control. 1 • More than 690, 000 adults experience an ischemic stroke in the United States each year. 2 • Stroke is an enormous source of morbidity due to the interplay between the resulting neurological impairment, the emotional and social consequences, and the high risk for recurrence.

Chronic Kidney Disease • CKD is defined as decreased kidney function that persists for three or more months. This diagnosis encompasses a continuum of diseases. • CKD is a significant global health concern with a prevalence of 15% in developed countries. 3 • In long-term dialysis patients stroke has a prevalence of 17% compared to 10% for non-dialysis CKD patients and 4% for the general population. 4 • Over 30% of ischemic stroke patients meet criteria for CKD. 5 • Yet studies investigating the effect of renal dysfunction on stroke severity and outcomes are limited and have provided conflicting results.

Explicit Guidelines • Hypertension • Dyslipidemia Notice: CKD is not included in this list • Glucose Disorders • Atrial Fibrillation • Obesity/Inactivity • Malnutrition • Sleep Apnea • Carotid Disease • Intracranial Atherosclerosis • Hypercoagulative States

Hypotheses & Specific Aims First Aim: Determine the association between CKD and stroke severity on presentation *We hypothesized that patients with CKD would present with greater stroke severity, as evidenced by higher NIH Stroke Scale scores. Second Aim: Determine the association between CKD and common stroke risk factors *We hypothesized that patients with CKD would have increased risk for comorbid DM, HTN, HLD, A-fib and tobacco use. Third Aim: Determine the association between CKD and vascular intervention for ischemic stroke management *We hypothesized that patients with CKD would have increased risk for undergoing stroke intervention. Fourth Aim: Determine the association between CKD and disposition following ischemic stroke *We hypothesized that patients with CKD would have increased risk for hospital discharge to a non-home facility.

NIH Stroke Scale Score Description 0 1 -4 5 -15 15 -20 21 -42 No stroke Minor stroke Moderate/severe stroke Severe stroke The National Institutes of Health Stroke Scale (NIHSS) is a 15 -item impairment scale used to measure stroke severity. It was originally developed in 1989 and is now widely used. In the current National Stroke Foundation guidelines, the NIHSS is recommended as a valid tool to assess stroke severity in emergency departments. 6

Catheter Interventions • Transcatheter therapy, arterial or venous infusion for thrombolysis • Percutaneous transluminal mechanical thrombectomy with intraprocedural pharmacological thrombolytic injection • Tissue plasminogen activator (t. PA): dissolves blood clots and reestablishes blood flow to the brain— administered within 4. 5 hours of symptom onset 7 • Endovascular thrombectomy: removes large blood clots by sending a wired-caged device to the site of the blocked blood vessel in the brain

Materials • HERON: The Healthcare Enterprise Repository for Ontological Narration • REDCap: Research Electronic Data Capture • SQLite • Microsoft Excel • SAS 9. 4

Stroke Patients Variables of Interest

Timeline Chronic Kidney Disease e. GFR < 60 m. L/min per 1. 73 m 2 for > 90 days *e. GFR does not improve to > 60 during this window* Stroke Encounter Stroke Diagnosis AND NIHSS Evaluation Disposition Intervention Atrial Fibrillation Diabetes Hypertension Hyperlipidemia Tobacco Use *Diagnosed previously or < 2 weeks following stroke*

ICD 9: Occlusion of Cerebral Arteries ICD 9: Transient Cerebral Ischemia ICD 9: Occlusion and Stenosis of Pre-cerebral Arteries ICD 10: Cerebral Infarction 4, 330 ICD 9: Occlusion of Cerebral Arteries ICD 9: Transient Cerebral Ischemia ICD 9: Occlusion and Stenosis of Pre-cerebral Arteries ICD 10: Cerebral Infarction 4, 009 Stroke Diagnosis ‘Billing Diagnosis - Admit Primary‘ or 'Billing Diagnosis - Discharge Primary' 1, 494 patients 1, 567 encounters 1, 718 NIH Stroke Scale Score in Same Encounter as Stroke Diagnosis (Primary)

1, 567 Studied Encounters 1, 292 Non-CKD (82. 45%) 275 CKD (17. 55%) September 2012 – August 2017

RESULTS

Demographics White Black Other Total Female Male Total 537 601 1138 34. 27% 38. 35% 72. 62% 127 154 281 8. 10% 9. 83% 17. 93% 58 90 148 3. 70% 5. 74% 9. 44% 722 845 1567 46. 08% 53. 92% 100%

White Black Non-CKD Other Total White Black Other Total Female Male Total 441 528 969 34. 13% 40. 87% 75. 00% 79 112 191 6. 11% 8. 67% 14. 78% 51 81 132 3. 95% 6. 27% 10. 22% 571 721 1292 44. 20% Female Male Total 96 73 169 34. 91% 26. 55% 61. 45% 48 42 90 17. 45% 15. 27% 32. 73% 7 9 16 2. 55% 3. 27% 5. 82% 151 124 275 54. 91% 45. 09% 100% 55. 80% 100% CKD

Age

First Aim: Stroke Scale Score

Second Aim: Chronic Atrial Fibrillation 1. 0

Second Aim: Diabetes

Second Aim: Hypertension

Second Aim: Hyperlipidemia

Second Aim: Tobacco Use 1. 0

Third Aim: Intervention

Fourth Aim: Discharge Disposition 1. 0

Conclusions • CKD is not associated with greater stroke severity upon hospital presentation at KUMC. • CKD is strongly associated with diabetes, hypertension, and hyperlipidemia in ischemic stroke patients. • The odds of undergoing catheter intervention are lower in patients with CKD than in those with normal kidney function. • There is no association between CKD and discharge disposition at KUMC.

Limitations • CKD definition • Lack of distinction between ESRD and CKD • Limited flowsheet data • NIH Stroke Scale

Future Directions • Prospective Studies • Stroke Impact Scale • Modified Rankin Scale • Malignant Hypertension • Hemorrhagic Strokes • Repeat Stroke Events

References 1. What Is a Stroke? - NHLBI, NIH. https: //www. nhlbi. nih. gov/health-topics/stroke. Accessed December 11, 2017. 2. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics--2014 update: a report from the American Heart Association. Circulation. 2014; 129(3): e 28 -e 292. doi: 10. 1161/01. cir. 0000441139. 02102. 80. 3. Couser WG, Remuzzi G, Mendis S, Tonelli M. The contribution of chronic kidney disease to the global burden of major noncommunicable diseases. Kidney Int. 2011; 80(12): 1258 -1270. doi: 10. 1038/ki. 2011. 368. 4. Bugnicourt J-M, Godefroy O, Chillon J-M, Choukroun G, Massy ZA. Cognitive disorders and dementia in CKD: the neglected kidney-brain axis. J Am Soc Nephrol JASN. 2013; 24(3): 353 -363. doi: 10. 1681/ASN. 2012050536. 5. Hayden D, Mc. Carthy C, Akijian L, et al. Renal dysfunction and chronic kidney disease in ischemic stroke and transient ischemic attack: A population-based study. Int J Stroke Off J Int Stroke Soc. 2017; 12(7): 761 -769. doi: 10. 1177/1747493017701148. 6. Kwah LK, Diong J. National Institutes of Health Stroke Scale (NIHSS). J Physiother. 2014; 60(1): 61. doi: 10. 1016/j. jphys. 2013. 12. 012. 7. Stroke Treatments. http: //www. strokeassociation. org/STROKEORG/About. Stroke/BLS/Stroke. Treatments_UCM_310892_Article. jsp#. Accessed December 11, 2017.

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