Letter to the Editor Stroke welcomes Letters to the Editor and will publish them, if suitable, as space permits. Letters must reference a Stroke published-ahead-of-print article or an article printed within the past 3 weeks. The maximum length is 750 words including no more than 5 references and 3 authors. Please submit letters typed double-spaced. Letters may be shortened or edited.
Response to Letter Regarding Article, “Severe Renal Impairment Is Associated With Symptomatic Intracerebral Hemorrhage After Thrombolysis for Ischemic Stroke”
We thank Dr Power for his interest in our article. Indeed, a research interface between nephrology and neurology is essential to understand mechanism of stroke and its therapeutics in patients with kidney disease. We totally agree with Dr Power that using a single calculated estimated glomerular filtration rate (eGFR) value resembles a snapshot of renal function only. Several preadmission measurements and complementary tests would have allowed for a more detailed picture of renal function.1 Having said that, it would have been difficult to obtain these measurements before stroke in our research setting because many patients had not seen a doctor for years let alone had renal function tests. The association between eGFR at the time of acute stroke and the risk of symptomatic intracerebral hemorrhage (sICH) after thrombolysis holds true. The association does not necessarily apply to patients on dialysis because these were excluded from our analysis (see Method section of this article).2 Neither does it inevitably imply to withhold an evidence-based therapy as thrombolysis. This conclusion would have to be based on comparisons between patients with stroke (with renal impairment) with and without thrombolysis. Dr Power mentions the report by Tariq et al3 on outcomes of thrombolytic therapy in dialysis-dependent patients with stroke. They did not find a significant association between dialysis dependency and occurrence of sICH. However, they missed to adjust for well-established risk factors for sICH (eg, onset to treatment time, stroke severity [National Institutes of Health Stroke Scale], glucose on admission, or systolic blood pressure). Besides, they did not report on eGFR at the time of acute stroke.4 In matters of confounding factors Dr Power is correct to request data on the intensity of antiplatelet therapy. Both single and dual
antiplatelet therapies have been linked to an increased risk for sICH by some but not all previous analyses. As far as our cohort is concerned, neither single nor dual antiplatelet therapies have influenced our finding that eGFR at the time of stroke was significantly associated with risk of sICH. To our reassurance, a recently published large multicentre study confirmed our results. Gensicke et al5 also found a significant association between impaired renal function (expressed by a single calculated eGFR value on admission) and risk of sICH after thrombolysis in acute stroke. They also adjusted for antiplatelet therapy. Serdar Tütüncü, MD Annerose M. Ziegler, MD Christian H. Nolte, MD Department of Neurology Charité-Universitätsmedizin Berlin, Germany 1. Srisawat N, Kellum JA. Acute kidney injury: definition, epidemiology, and outcome. Curr Opin Crit Care. 2011;17:548–555. 2. 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;44:3217–3219. 3. Tariq N, Adil MM, Saeed F, Chaudhry SA, Qureshi AI. Outcomes of thrombolytic treatment for acute ischemic stroke in dialysis-dependent patients in the United States. J Stroke Cerebrovasc Dis. April 28, 2013. http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2013.03.016. Accessed November 20, 2013. 4. Mazya M, Egido JA, Ford GA, Lees KR, Mikulik R, Toni D, et al.; SITS Investigators. Predicting the risk of symptomatic intracerebral hemorrhage in ischemic stroke treated with intravenous alteplase: safe Implementation of Treatments in Stroke (SITS) symptomatic intracerebral hemorrhage risk score. Stroke. 2012;43:1524–1531. 5. Gensicke H, Zinkstok SM, Roos YB, Seiffge DJ, Ringleb P, Artto V, et al. IV thrombolysis and renal function. Neurology. 2013;81:1780–1788.
(Stroke. 2014;45:e29.) © 2014 American Heart Association, Inc. Stroke is available at http://stroke.ahajournals.org
DOI: 10.1161/STROKEAHA.113.003934
Downloaded from http://stroke.ahajournals.org/e29 at VA MED CTR BOISE on November 15, 2015
Response to Letter Regarding Article, ''Severe Renal Impairment Is Associated With Symptomatic Intracerebral Hemorrhage After Thrombolysis for Ischemic Stroke'' Serdar Tütüncü, Annerose M. Ziegler and Christian H. Nolte Stroke. 2014;45:e29; originally published online January 2, 2014; doi: 10.1161/STROKEAHA.113.003934 Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2014 American Heart Association, Inc. All rights reserved. Print ISSN: 0039-2499. Online ISSN: 1524-4628
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://stroke.ahajournals.org/content/45/2/e29
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Stroke can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Stroke is online at: http://stroke.ahajournals.org//subscriptions/
Downloaded from http://stroke.ahajournals.org/ at VA MED CTR BOISE on November 15, 2015
Response to Letter Regarding Article, “Severe Renal Impairment Is Associated With Symptomatic Intracerebral Hemorrhage After Thrombolysis for Ischemic Stroke”
We thank Dr Power for his interest in our article. Indeed, a research interface between nephrology and neurology is essential to understand mechanism of stroke and its therapeutics in patients with kidney disease. We totally agree with Dr Power that using a single calculated estimated glomerular filtration rate (eGFR) value resembles a snapshot of renal function only. Several preadmission measurements and complementary tests would have allowed for a more detailed picture of renal function.1 Having said that, it would have been difficult to obtain these measurements before stroke in our research setting because many patients had not seen a doctor for years let alone had renal function tests. The association between eGFR at the time of acute stroke and the risk of symptomatic intracerebral hemorrhage (sICH) after thrombolysis holds true. The association does not necessarily apply to patients on dialysis because these were excluded from our analysis (see Method section of this article).2 Neither does it inevitably imply to withhold an evidence-based therapy as thrombolysis. This conclusion would have to be based on comparisons between patients with stroke (with renal impairment) with and without thrombolysis. Dr Power mentions the report by Tariq et al3 on outcomes of thrombolytic therapy in dialysis-dependent patients with stroke. They did not find a significant association between dialysis dependency and occurrence of sICH. However, they missed to adjust for well-established risk factors for sICH (eg, onset to treatment time, stroke severity [National Institutes of Health Stroke Scale], glucose on admission, or systolic blood pressure). Besides, they did not report on eGFR at the time of acute stroke.4 In matters of confounding factors Dr Power is correct to request data on the intensity of antiplatelet therapy. Both single and dual
antiplatelet therapies have been linked to an increased risk for sICH by some but not all previous analyses. As far as our cohort is concerned, neither single nor dual antiplatelet therapies have influenced our finding that eGFR at the time of stroke was significantly associated with risk of sICH. To our reassurance, a recently published large multicentre study confirmed our results. Gensicke et al5 also found a significant association between impaired renal function (expressed by a single calculated eGFR value on admission) and risk of sICH after thrombolysis in acute stroke. They also adjusted for antiplatelet therapy. Serdar Tütüncü, MD Annerose M. Ziegler, MD Christian H. Nolte, MD Department of Neurology Charité-Universitätsmedizin Berlin, Germany 1. Srisawat N, Kellum JA. Acute kidney injury: definition, epidemiology, and outcome. Curr Opin Crit Care. 2011;17:548–555. 2. 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;44:3217–3219. 3. Tariq N, Adil MM, Saeed F, Chaudhry SA, Qureshi AI. Outcomes of thrombolytic treatment for acute ischemic stroke in dialysis-dependent patients in the United States. J Stroke Cerebrovasc Dis. April 28, 2013. http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2013.03.016. Accessed November 20, 2013. 4. Mazya M, Egido JA, Ford GA, Lees KR, Mikulik R, Toni D, et al.; SITS Investigators. Predicting the risk of symptomatic intracerebral hemorrhage in ischemic stroke treated with intravenous alteplase: safe Implementation of Treatments in Stroke (SITS) symptomatic intracerebral hemorrhage risk score. Stroke. 2012;43:1524–1531. 5. Gensicke H, Zinkstok SM, Roos YB, Seiffge DJ, Ringleb P, Artto V, et al. IV thrombolysis and renal function. Neurology. 2013;81:1780–1788.
(Stroke. 2014;45:e29.) © 2014 American Heart Association, Inc. Stroke is available at http://stroke.ahajournals.org
DOI: 10.1161/STROKEAHA.113.003934
Downloaded from http://stroke.ahajournals.org/e29 at VA MED CTR BOISE on November 15, 2015
Response to Letter Regarding Article, ''Severe Renal Impairment Is Associated With Symptomatic Intracerebral Hemorrhage After Thrombolysis for Ischemic Stroke'' Serdar Tütüncü, Annerose M. Ziegler and Christian H. Nolte Stroke. 2014;45:e29; originally published online January 2, 2014; doi: 10.1161/STROKEAHA.113.003934 Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2014 American Heart Association, Inc. All rights reserved. Print ISSN: 0039-2499. Online ISSN: 1524-4628
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://stroke.ahajournals.org/content/45/2/e29
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Stroke can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Stroke is online at: http://stroke.ahajournals.org//subscriptions/
Downloaded from http://stroke.ahajournals.org/ at VA MED CTR BOISE on November 15, 2015
