Intravenous tPA hemorrhage risk in the renally impaired
Claude Nguyen, MD
Tütüncü S, Ziegler AM, Scheitz JF, Slowinski T, Rocco A, Endres M, et al. Severe Renal Impairment Is Associated With Symptomatic Intracerebral Hemorrhage After Thrombolysis for Ischemic Stroke. Stroke. 2013
Intravenous tPA affords varying degrees of risk based on the patient’s medical history. One of the areas thought to put patients at higher risk is renal impairment. Tutuncu et al. looked at this by retrospectively reviewing 740 patients who received IV tPA. Excluding those on dialysis, a large proportion of them (83%) had renal impairment, with 5% being severe impairment (GFR <30ml/min). In the group with severe impairment, there was a higher proportion of patients with symptomatic ICH and parenchymal hemorrhage, even after adjusting for variables such as age, hypertension history, and peripheral arterial disease.
The authors go on to hypothesize that the reason for increased bleeding risk could be related to endothelial platelet dysfunction, as well as worsening white matter disease in those patients. The group points out that they were unable to account for the severity of preexisting white matter disease in their model, and that their findings were based on one creatinine reading upon admission. Despite these limitations and its retrospective nature, these results are slowly helping to better define individual risk in thrombolytic therapy, and a reminder that IV tPA is not a “one-size-fits-all” medication.