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Oakley final presentation
1. Chronic Kidney Disease in
Ischemic Stroke
Carlee Oakley
University of Kansas Medical Center
PVRM 868 Biomedical Informatics Driven Clinical
Research
2017
3. 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.
4.
5. 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.
6. Explicit Guidelines
• Hypertension
• Dyslipidemia
• Glucose Disorders
• Atrial Fibrillation
• Obesity/Inactivity
• Malnutrition
• Sleep Apnea
• Carotid Disease
• Intracranial Atherosclerosis
• Hypercoagulative States
Notice: CKD is not included
in this list
7. 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.
8. NIH Stroke Scale
Score Description
0 No stroke
1-4 Minor stroke
5-15 Moderate stroke
15-20 Moderate/severe stroke
21-42 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
9. Catheter Interventions
• Transcatheter therapy, arterial or venous infusion for
thrombolysis
• Percutaneous transluminal mechanical thrombectomy
with intraprocedural pharmacological thrombolytic
injection
• Tissue plasminogen activator (tPA): dissolves blood
clots and reestablishes blood flow to the brain—
administered within 4.5 hours of symptom onset7
• Endovascular thrombectomy: removes large blood
clots by sending a wired-caged device to the site of
the blocked blood vessel in the brain
10. Materials
• HERON: The Healthcare Enterprise Repository for
Ontological Narration
• REDCap: Research Electronic Data Capture
• SQLite
• Microsoft Excel
• SAS 9.4
12. Timeline
Stroke Encounter
Stroke Diagnosis
AND
NIHSS Evaluation
Disposition
Intervention
Atrial Fibrillation
Diabetes
Hypertension
Hyperlipidemia
Tobacco Use
*Diagnosed previously or
< 2 weeks following stroke*
Chronic Kidney Disease
eGFR < 60 mL/min per 1.73m2
for > 90 days
*eGFR does not improve to
> 60 during this window*
13. ICD9: Occlusion of Cerebral Arteries
ICD9: Transient Cerebral Ischemia
ICD9: Occlusion and Stenosis of Pre-cerebral Arteries
ICD10: Cerebral Infarction
4,330
ICD9: Occlusion of Cerebral Arteries
ICD9: Transient Cerebral Ischemia
ICD9: Occlusion and Stenosis of Pre-cerebral Arteries
ICD10: Cerebral Infarction
4,009
Stroke Diagnosis
‘Billing Diagnosis - Admit Primary‘
or
'Billing Diagnosis - Discharge Primary'
1,718
NIH Stroke Scale Score
in Same Encounter
as
Stroke Diagnosis (Primary)
1,494 patients
1,567 encounters
27. 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.
30. References
1. What Is a Stroke? - NHLBI, NIH. https://www.nhlbi.nih.gov/health/health-topics/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):e28-e292.
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, McCarthy 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/AboutStroke/BLS/Stroke-
Treatments_UCM_310892_Article.jsp#. Accessed December 11, 2017.
