Under-recognized post-stroke acute kidney injury: risk factors and relevance for stroke outcome of a frequent comorbidity.

BACKGROUND: Acute kidney injury (AKI) is emerging as a predictor of poor stroke outcome, however, it is often not recognized. The aim of our study was to evaluate post-stroke AKI burden, AKI risk factors and their influence in post-stroke outcome. METHODS: From 2013 to 2016, 440 individuals with stroke diagnosis admitted in Stroke Unit, Foundation IRCCS Policlinico San Matteo (Pavia, Italy), were retrospectively enrolled. AKI cases identified by KDIGO criteria through the electronic database and hospital chart review were compared with the ones reported in discharge letters or in administrative hospital data base. Mortality data were provided by Agenzia Tutela della Salute of Pavia. RESULTS: We included 430 patients in the analysis. Median follow-up was 19.2 months. We identified 79 AKI cases (18% of the enrolled patients, 92% classified as AKI stage 1), a fivefold higher number of cases than the ones reported at discharge. 37 patients had AKI at the admission in the hospital, while 42 developed AKI during the hospitalization. Cardioembolic (p = 0.01) and hemorrhagic (p = 0.01) stroke types were associated with higher AKI risk. Admission National Institutes of Health Stroke Scale (NIHSS, p < 0.05) and Charlson Comorbidity Index (p < 0.01) were independently associated with overall AKI, while admission NIHSS (p < 0.05) and eGFR (p < 0.005) were independently associated with AKI developed during the hospitalization. AKI was associated to longer in-hospital stay (p = 0.01), worse Rankin Neurologic Disability Score at discharge (p < 0.0001) and discharge disposition other than home (p = 0.03). AKI was also independently associated to higher in-hospital mortality (OR 3.9 95% CI 1.2-12.9 p = 0.023) but not with long-term survival. CONCLUSIONS: Post-stroke AKI diagnosis needs to be improved by strictly monitoring individuals with cardioembolic or hemorrhagic stroke, reduced kidney function, higher Charlson Comorbidity Index and worse NIHSS at presentation.

[Management of stroke in a ward of internal medicine. Limits and prospects]. / La gestione dell'ictus in un reparto di Medicina Interna. Limiti e prospettive.

Precocious admission to specifically "dedicated" wards proved to improve reduction of mortality and degree of residual disability in patients with stroke, even if their inhomogeneous distribution gets most patients admitted to wards of Internal Medicine. We purposed to evaluate the importance of this problem, to check adhesion to the national guidelines and to show the main problems in management of patients with stroke in the Operative Unit of Internal Medicine, Vascular and Metabolic Diseases of the IRCCS S. Matteo Hospital of Pavia. 143 patients with stroke were admitted in 2001, 126 were ischemic, 17 hemorragic; the mean age was of 73. The most frequent risk factors were hypertension, diabetes, smoke and atrial fibrillation. 59% of patients were admitted within 6 hours from onset of symptoms. Within the ischemic subtypes, 17.5% were atherotrombothic, 16.7% cardioembolic, 23.8% lacunar and 42% with undetermined etiology. Lacunar syndromes were the most part. 80% of patients underwent computed tomography, 50% underwent epiaortic Doppler sonography, 38% echocardiography. 61% of ischemic subtypes underwent acute antiplatelet treatment. Complications were prevalent in oldest patients. Mortality of inpatients was 17%, influenced by age, hypertension, severe sensorial compromission at admission, cardioembolism and complications. This study proved leak of adhesion to national guidelines which brought to inadequate accuracy in diagnosis and difficulty in making correct and coherent therapeutic choices. At least in great hospitals, "dedicated" areas in wards of Internal Medicine with selected, trained and motivated staff should be desirable.