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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM ASIA–AFRICA  
Year : 2021  |  Volume : 32  |  Issue : 1  |  Page : 199-203
Role of Renal Dysfunction as a Prognostic Factor in Acute Stroke Patients at a Tertiary Hospital in Northeastern Nigeria


1 Department of Medicine, Renal Unit, University of Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria
2 Department of Medicine, Neurology Unit, University of Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria
3 Department of Radiology, University of Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria

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Date of Web Publication16-Jun-2021
 

   Abstract 


Chronic kidney disease (CKD) and stroke share many common risk factors, and the presence of CKD confers added risk factors for stroke. With increasing interest and understanding of the close relationship between the kidney and the brain, this study aims to assess the prevalence and impact of renal dysfunction on outcomes acute stroke patients. This is a prospective hospital-based study carried out in the neurology unit of University of Maiduguri Teaching Hospital, Maiduguri, northeastern Nigeria. The study population consisted of adult patients (>18 years) admitted in the medical wards with a diagnosis of acute stroke. Sociodemographic variables and biochemical parameters were obtained from each patient. Patients’ functional status assessment by modified Rankin scale, Barthel index, and National Institutes of Health Stroke Scale score were obtained at admission and discharge. Glomerular filtration rate (GFR) was calculated using the modification of diet in renal disease equation. Patients who have estimated GFR (eGFR) <60 mL/min/1.73 m2 were considered to have CKD. Patients were grouped into A: with GFR <60 mL/min and B: GFR >60 mL/min. Out of a total of 501 patients admitted during the study period, 448 patients had complete data and were recruited, out of which 275 (61.4%) were male and 173 (38.6%) were female. Their ages ranged from 38 to 89 years, with a mean age ± standard deviation of 53.85 ± 18.13 years. The mean eGFR of the study population was 66.55 ± 30.49 mL/min. Two hundred and twenty-five (50.2%) had renal dysfunction with GFR <60 mL/min. The mean GFR of patients with renal dysfunction was 32.84 ± 27.59 mL/min, and patients without renal dysfunction had a mean GFR of 73.68 ± 35.61 mL/min. Patients with renal dysfunction on admission had Barthel stroke score of 20.74 ± 18.74 as compared to patients without renal dysfunction (25.49 ± 20.34), P = 0.017. At discharge, the Barthel scores for the two groups were 53.87 ± 30.17 and 41.71 ± 30.29 (P = 0.000), respectively. Patients with renal dysfunction had longer hospital stay with a mean duration on admission of 45.66 ± 39.90 days and severe residual disability at discharge. Acute stroke patients who have associated renal dysfunction have severe disability on admission and discharge. Renal dysfunction is common among acute stroke patients.

How to cite this article:
Sulaiman MM, Watila MM, Shettima J, Ummate I, Nyandaiti YW. Role of Renal Dysfunction as a Prognostic Factor in Acute Stroke Patients at a Tertiary Hospital in Northeastern Nigeria. Saudi J Kidney Dis Transpl 2021;32:199-203

How to cite this URL:
Sulaiman MM, Watila MM, Shettima J, Ummate I, Nyandaiti YW. Role of Renal Dysfunction as a Prognostic Factor in Acute Stroke Patients at a Tertiary Hospital in Northeastern Nigeria. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2021 Jul 27];32:199-203. Available from: https://www.sjkdt.org/text.asp?2021/32/1/199/318524



   Introduction Top


Stroke is defined as sudden onset of focal or global neurologic deficit of vascular origin.[1] It is the second most common cause of death worldwide and the leading cause of disability in Africa.[2],[3] The WHO has estimated that stroke accounts for 10.8% of global mortality and 3.1% of disease burden worldwide.[3] In 2005, an estimated 5.7 million deaths were attributable to stroke globally, and it was estimated that 87% of these deaths occurred in low- and middle-income countries of the world.[4] In Nigeria, stroke prevalence has been reported to range from 116 to 316/100,000 population, and it accounts for 0.9% to 4.0% of medical admissions.[4],[5],[6],[7] Stroke has two main subtypes: ischemic stroke and hemorrhagic stroke. Ischemic stroke is by far the most common type of stroke accounting for 85% of all strokes, whereas hemorrhagic stroke is responsible for the remaining.[6] Various risk factors have been found to contribute to the development of stroke such as hypertension, diabetes mellitus, dyslipidemia and atherosclerosis, and obesity.[8] Incidentally, chronic kidney disease (CKD) shares similar risk factors as stroke, and the presence of CKD predisposes the patients to nontraditional cardiovascular disease risk factors such as anemia, hyperparathyroidism, hypocalcemia, and hyperphosphatemia.[9]

The close interaction between the brain and the kidney is receiving recognition and attention of researchers. CKD and albuminuria increase the risk of stroke by 71%–92%.[10] A strong relationship has been established between CKD and subclinical brain damages such as white matter changes, microbleeds, cognitive impairment, and carotid atherosclerosis. Thus, the prevalence of CKD in ischemic and hemorrhagic stroke subtypes has been shown to be 46% and 39%, respectively.[10]

Renal disease also impacts the treatment modalities and outcomes for acute stroke. Blood levels of antithrombotic and thrombolytic drugs are affected by renal disease. Dialysis patients are at higher risk of developing stroke compared to the general population. Factors that contribute to the development of stroke among dialysis patients include drastic hemodynamic changes, dialysate anticoagulants, vascular calcification, and high prevalence of traditional risk factors.[11]

The outcome of stroke in CKD patients is worse than patients without CKD. Reduced glomerular filtration rate (GFR) is associated with higher 1- and 10-year mortality. They also have poorer functional outcome than patients without renal dysfunction.[12],[13],[14],[15],[16]

Recently attention has been focused on identifying factors that predict poor outcome in stroke patients so that mitigating them can result in more favorable outcomes. Factors, such as fever, hyperglycemia, and hemorrhagic stroke type, have been well established as predictors of poor outcomes in stroke patients. We felt that it is imperative to examine the impact of renal dysfunction on outcomes in stroke patients in Nigeria and hence this study.


   Methodology Top


The study is a prospective one carried out in the neurology unit of University of Maiduguri Teaching Hospital Maiduguri, northeastern Nigeria. The study population consisted of adult patients (>18 years) admitted in the medical wards with a diagnosis of acute stroke. Informed consent was obtained from each patient or caregiver, and institutional ethical clearance was also obtained. Socio-demographic variables and biochemical parameters were obtained from each patient. Patients’ functional status were assessed using Barthel index, and National Institutes of Health (NIH) stroke score obtained on admission and discharge. Each patient had measurement of packed cell volume using centrifuged micropipette blood samples, serum creatinine, urea, electrolytes, and cholesterol. Patients were grouped into A: with GFR <60 mL/min and B: GFR >60 mL/min. The data obtained were compared for the two groups. GFR was calculated using the modification of diet in renal disease equation. Patients who have eGFR <60 mL/min/1.73 m2 were considered to have CKD. Modified Rankin score is applied thus: 0: no symptoms; 1: no significant disability despite symptoms, able to carry out all usual duties and activities; 2: slight disability, unable to carry out all previous activities; 3: moderate disability: requiring some help, but able to walk without assistance; and 4: moderately severe disability, unable to walk without assistance and unable to attend. The Barthel index is applied to all patients at admission and at discharge.


   Results Top


Out of a total of 501 acute stroke patients admitted into the medical wards of University of Maiduguri Teaching Hospital between January 2014 and December 2016, 448 had complete renal function tests done and were included in the study. There were 275 (61.4%) males and 173 (38.6%) females. Their ages ranged from 38 to 89 years, with a mean age ± standard deviation of 53.85 ± 18.13 years. The mean eGFR of the study population was 66.55 ± 30.49 mL/min. The distribution of patients according to their GFR is shown in [Figure 1].
Figure 1: Distribution of glomerular filtration rate in the study population.

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The study population was divided into two groups based on GFR on admission; there were 225 (50.2%) with an eGFR of the <60 mL/min GFR and 223 (49.8%) with an eGFR >60 mL/min. The mean GFR was 32.84 ±2 7.59 mL/min in the CKD group. Hypertension and serum cholesterol levels were higher in the CKD group. The characteristics of the two groups are as contained in [Table 1].
Table 1: Comparison of sociodemographic and laboratory parameters between patients with estimated glomerular filtration rate <60 mL/min and >60 mL/min.

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   Discussion Top


Fifty percent of the patients admitted in our hospital with acute stroke have eGFR <60 mL/min/1.73 m2 which exceeded the population prevalence of CKD in Nigeria of 26%. This may be because CKD patients are at higher risk of developing stroke than normal population. Toyoda[10] have shown that proteinuria increased the risk of stroke by 71%–92%. Studies have consistently reported a higher prevalence of renal disease among stroke patients.[3],[4],[10],[12] CKD worsens peculiar risk factors for stroke such as endothelial dysfunction, maladaptive arterial remodeling, hyperhomocysteinemia, increased inflammatory cytokines, and oxidative stress which promote the development of stroke. The presence of other factors such as dehydration and urinary tract infections are common in stroke patients and may have played some role in these patients. In this study, we found that patients with eGFR <60 mL/min had more profound disability on admission and at discharge. They also have a longer hospital stay when compared to patients without CKD. CKD carries poor prognosis among stroke patients.


   Conclusion Top


CKD is common among patients admitted with acute stroke in northeastern Nigeria. Patients have longer hospital stay and poorer outcomes than those without kidney disease. Patients with stroke should be screened for kidney disease, and attention should be given toward alleviating their renal dysfunction.

Conflict of interest: None declared.



 
   References Top

1.
Smith SW, Johnston CS, Hemphil JC. Cerebrovascular diseases. In: Kasper DL, Hauser SL, Jameson JL, Fauci AS, Longo DL, Loscalzo J, editors. Harrison’s Principles of Internal Medicine. 20th ed. McGraw-Hill, Philadelphia 2018 p. 3460-87.  Back to cited text no. 1
    
2.
Owolabi MO, Akarolo-Anthony S, Akinyemi R, et al. The burden of stroke in Africa: A glance at the present and a glimpse into the future. Cardiovasc J Afr 2015;26:S27-38.  Back to cited text no. 2
    
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Koren-Morag N, Goldbourt U, Tanne D. Renal dysfunction and risk of ischemic stroke or TIA in patients with cardiovascular disease. Neurology 2006;67:224-8.  Back to cited text no. 3
    
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Tsagalis G, Akrivos T, Alevizaki M, et al. Renal dysfunction in acute stroke: An independent predictor of long-term all combined vascular events and overall mortality. Nephrol Dial Transplant 2009;24:194-200.  Back to cited text no. 4
    
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Piccni JP, Stevens SR, Chang Y, et al. Renal dysfunction as a predictor of stroke and syatemic embolism in patients with non-valvular atrial fibrillation: Validation of the R2 CHADS2 index. Circulation 2013;127:224-32.  Back to cited text no. 5
    
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Hojs Fabjan T, Hojs R, Tetickovic E, Pecovnik Balon B. Ischaemic stroke – impact of renal dysfunction on in-hospital mortality. Eur J Neurol 2007;14:1351-6.  Back to cited text no. 6
    
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Holzmann MJ, Aastveit A, Hammar N, Jungner I, Walldius G, Holme I. Renal dysfunction increases the risk of ischemic and hemorrhagic stroke in the general population. Ann Med 2012;44:607-15.  Back to cited text no. 7
    
8.
Wang IK, Lien LM, Lee JT, et al. Renal dysfunction increases the risk of recurrent stroke in patients with acute ischemic stroke. Atherosclerosis 2018;277:15-20.  Back to cited text no. 8
    
9.
Agrawal V, Rai B, Fellows J, McCullough PA. In-hospital outcomes with thrombolytic therapy in patients with renal dysfunction presenting with acute ischaemic stroke. Nephrol Dial Transplant 2010;25:1150-7.  Back to cited text no. 9
    
10.
Toyoda K. Brain, stroke and kidney. Contrib Nephrol 2013;176:1-6.  Back to cited text no. 10
    
11.
National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification, and stratification. Am J Kidney Dis 2002;39:S1-266.  Back to cited text no. 11
    
12.
Busari AA, Amira CO, Bello BT, Okubadejo NU, Abdusalam IA. Renal dysfunction and 30 day mortality risk in patients with acute stroke. Afr J Nephrol 2019;22:28-34.  Back to cited text no. 12
    
13.
Ovbiagele B, Schwamm LH, Smith EE, et al. Hospitalized hemorrhagic stroke patients with renal insufficiency: Clinical characteristics, care patterns, and outcomes. J Stroke Cerebrovasc Dis 2014;23:2265-73.  Back to cited text no. 13
    
14.
Tsukamoto Y, Takahashi W, Takizawa S, Kawada S, Takagi S. Chronic kidney disease in patients with ischemic stroke. J Stroke Cerebrovasc Dis 2012;21:547-50.  Back to cited text no. 14
    
15.
Yahalom G, Schwartz R, Schwammenthal Y, et al. Chronic kidney disease and clinical outcome in patients with acute stroke. Stroke 2009;40:1296-303.  Back to cited text no. 15
    
16.
Kim HJ, Kim JK, Oh MS, Kim SG, Yu KH, Lee BC. A low baseline glomerular filtration rate predicts poor clinical outcome at 3 months after acute ischemic stroke. J Clin Neurol 2015;11:73-9.  Back to cited text no. 16
    

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Correspondence Address:
Mohammad Maina Sulaiman
Department of Medicine, Renal Unit, University of Maiduguri, PMB 1069, Maiduguri, Borno State
Nigeria
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DOI: 10.4103/1319-2442.318524

PMID: 34145131

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