Thrombolysis for Acute Stroke in Hemodialysis

Abstract

SummaryBackground and objectives Although data are absent, it has been stated that thrombolysis is probably not safe in the treatment of acute stroke in patients undergoing hemodialysis. The objective of this study was for stroke experts to define the range of management concerning thrombolytic treatment of acute stroke in hemodialysis.Design, setting, participants, & measurements Sixty-five stroke experts in thrombolytic therapy of acute ischemic stroke were queried regarding their personal experience in the use of thrombolysis in hemodialysis patients. Hypothetical case scenarios were presented. ResultsOf the 65 stroke experts who were queried, 40 (62%) responded. One-third of the responders had previously treated hemodialysis patients with recombinant tissue-type plasminogen activator (rt-PA). Most favored use of intravenous rt-PA for hemodialysis patients with acute ischemic stroke. When presented with a case of a patient who had recently undergone dialysis with a mildly prolonged activated partial thromboplastin time (aPTT), 50% favored immediate intravenous thrombolysis. Seventy-eight percent of the experts would have considered an intra-arterial approach and would have preferred mechanical clot retrieval to thrombolysis. ConclusionsDespite the acknowledged absence of data and prevalent concerns about bleeding risk, most surveyed experts favored its use. One-third reported treating hemodialysis patients with this therapy. Although these results do not substitute for data, they usefully define the range of current practice of stroke experts.

Stroke and Chronic Kidney Disease: Epidemiology, Pathogenesis, and Management Across Kidney Disease Stages

“…96 This lack of experience and comfort with treating dialysis patients with tPA was reflected in a recent survey of 40 stroke experts; only one third of the experts had experience with using tPA for ischemic stroke in dialysis patients whereas half reported reservations related to concerns about higher bleeding risk. 97 In this study, when presented with the hypothetical scenario of a hemodialysis patient presenting with an ischemic stroke shortly after finishing a session of HD with a mildly prolonged aPTT, only 17 of 40 experts would have treated with intravenous tPA whereas the rest cited guidelines regarding prolonged aPTT and heparin use being contraindicated to tPA use.…”

Correlations of MTHFR 677C>T Polymorphism with Cardiovascular Disease in Patients with End-Stage Renal Disease: A Meta-Analysis

“…HD is the most common procedure performed for patients with end-stage renal disease (ESRD), with an estimation of 1.5 million ESRD patients receiving HD worldwide [2]. Despite its important role in treating ESRD, HD also serves as a multiplier for other vascular risk factors, contributing to an increased incidence of cardiovascular disease, such as atrial fibrillation and myocardial ischemia [3], [4].…”

Acute Stroke Thrombolysis in End-Stage Renal Disease: A National Survey of Nephrologist Opinion

“…Concerns regarding bleeding resonate with those of stroke physicians and remain an enduring treatment dilemma [7]. Higher bleeding rates with declining renal function in primary thrombolysis for myocardial infarction have been reported in a Swedish registry study but it is unclear whether this is an effect of treatment choice or renal dysfunction per se [8].…”

“…The absence of trial data on the safety of thrombolysis in ESRD was reinforced as a significant issue in our study. Previously 78% of stroke experts favoured intra-arterial approaches rather than systemic thrombolysis in HD [7]. …”

“…It can therefore be hypothesised that the haemorrhagic risk of thrombolysis may outweigh any benefits. This concerned the majority of stroke experts polled in the only previous survey conducted on this topic [7]. …”