|Year : 2016 | Volume
| Issue : 1 | Page : 23-27
Estimated glomerular filtration rate in relation to intracerebral hemorrhage in Saudi Arabia
Magdy A Mostafa1, Nevine A Mohamed2
1 Department of Neurology, Ain Shams University, Cairo, Egypt; Department of Neurology, King Abdulaziz Hospital, Mecca, Kingdom of Saudi Arabia
2 Department of Clinical Pathology, Ain Shams University, Cairo, Egypt
|Date of Submission||13-Apr-2015|
|Date of Acceptance||28-Jul-2015|
|Date of Web Publication||15-Feb-2016|
Magdy A Mostafa
MD, Department of Neurology, King Abdulaziz Hospital, Mecca, Kingdom of Saudi Arabia
Source of Support: None, Conflict of Interest: None
Renal dysfunction has been implicated as a risk factor for adverse outcomes after numerous cardiovascular events including stroke. However, most of the stroke studies have focused on ischemic stroke but no enough studies were done on intracerebral hemorrhage.
We aimed to determine if renal dysfunction can affect the prognosis after intracerebral hemorrhage especially on the short-term period.
Patients and methods
A total of 60 patients with the diagnosis of intracerebral hemorrhage for the first time were included in this study. They were 17 female (28%) and 43 males (72%). Their age ranged from 35 to 89 years with median value of 60 years. On admission, all patients were subjected to full clinical assessment and brain computed tomography scan to measure the size of hematoma and calculate the intracerebral hemorrhage score. Glomerular filtration rate was estimated on admission using the Cockcroft-Gault equation.
There was a significant inverse relation between estimated glomerular filtration rate and hematoma size; also significant negative correlation was found between estimated glomerular filtration rate and intracerebral hemorrhage score (P < 0.05).On the other hand increase in serum creatinine was significantly associated with increase in the hematoma size and increase in the intracerebral hemorrhage score (P < 0.05).
Renal dysfunction has negative impact on the prognosis of intracerebral hemorrhage.
Keywords: Creatinine clearance, estimated glomerular filtration rate, intracerebral hemorrhage
|How to cite this article:|
Mostafa MA, Mohamed NA. Estimated glomerular filtration rate in relation to intracerebral hemorrhage in Saudi Arabia. Egypt J Neurol Psychiatry Neurosurg 2016;53:23-7
|How to cite this URL:|
Mostafa MA, Mohamed NA. Estimated glomerular filtration rate in relation to intracerebral hemorrhage in Saudi Arabia. Egypt J Neurol Psychiatry Neurosurg [serial online] 2016 [cited 2023 Sep 27];53:23-7. Available from: http://www.ejnpn.eg.net/text.asp?2016/53/1/23/176341
| Introduction|| |
The prognosis after the intracerebral hemorrhage (ICH) depends upon the location of hemorrhage (supra vs. infratentorial location), size of the hematoma, level of consciousness, patient age, and overall medical health and condition ,,. In addition, preceding oral anticoagulation therapy, and possibly antiplatelet therapy, appears to be associated with worse outcomes after ICH .
The ICH volume on initial head computed tomographic (CT) scan and level of consciousness on admission may be particularly important prognostic indicators. The ICH score is a useful easily calculated scale that allows a rough estimate of 30-days mortality. This scale incorporates several clinical components that may be independent predictors of outcome. Thirty-day mortality rates increased steadily with ICH score; mortality rates for ICH scores of 1, 2, 3, 4, and 5 were 13, 26, 72, 97, and 100%, respectively ,6]. The ICH score has been validated by retrospective  and prospective analysis ,. It may represent an early predictor of outcome in patients with intracerebral hematoma .
On the other hand, kidney dysfunction is a recognized risk factor for adverse outcomes after many cardiovascular events. For example, increased serum creatinine was found to be an independent predictor of both short-term (within 2 months) and long-term (6-12 months) mortality in patients with ischemic and hemorrhagic stroke. In addition, chronic kidney disease was implicated as an independent predictor of mortality and poor outcome 1 year after stroke .
However, the majority of patients in these studies had ischemic stroke and ICH cases were not specifically fully investigated in the immediate post-stroke period when adverse events frequently occur.
| Aim of work|| |
To assess the relation between renal function tests represented by serum creatinine and estimated glomerular filtration rate (GFR) and the size of intracerebral hematoma as well as the prognosis in such patients.
| Patients and methods|| |
This is a cross-sectional study done on 60 patients admitted with the diagnosis of ICH, who were recruited from King Abdulaziz Hospital in Mecca. The following exclusion criteria were applied:
- Past history of previous ischemic or hemorrhagic stroke,
- Previous history of renal impairment,
- Clinical or laboratory evidence of hepatic impairment, and
- Clinical or laboratory evidence of hematological disorder causing bleeding tendency.
All patients were subjected to full clinical assessment including history taking and full general and neurological examination, CT scan brain to diagnose ICH and to calculate the volume of intracerebral hematoma. Hematoma volume was measured on the initial head CT scan with the use of the ABC/2 method, in which A is the greatest diameter on the largest hemorrhage slice, B is the diameter perpendicular to A, and C is the approximate number of axial slices with hemorrhage multiplied by the slice thickness (10 mm). All scans were performed on Siemens Somaton Balance scanner (Siemens Company, Germany). All patients had assessment of ICH scores and full lab investigation including complete blood count, liver function test, coagulation profile and renal function test including serum creatinine and urea. Estimation of GFR (creatinine clearance) was calculated using the Cockcroft-Gault equation: [Estimated GFR (ml/min) = Sex×(140-age)/(serum creatinine)΄(weight/72)] where male = 1, female = 0.85, age in years, serum creatinine in mg%, and weight in kg . This study has been ethically approved by the local committee and all patients signed an informed consent before inclusion.
IBM SPSS statistics (version 22.0, 2013; IBM Corp., Armonk, New York, USA) was used for data analysis. Data was expressed as median and percentiles for quantitative nonparametric measures. The ranked Spearman correlation test was used to study the possible association between each two variables for nonparametric data. The probability of error at 0.05 was considered significant, while at 0.01 and 0.001 are highly significant.
| Results|| |
Sixty patients diagnosed as ICH were studied including 17 female (28%) and 43 males (72%). Their age ranged from 35 to 89 years with median value of 60 years. CT scan brain was used to measure the size of hematoma. ICH score was calculated for each patient, assessment of renal functions including serum urea and creatinine was done. Creatinine clearance was calculated as indicator of estimated GFR according to the Cockcroft-Gault equation . The range, median value, and the 25th and the 75th percentiles for each parameter were shown in [Table 1].
On studying the possible association between renal function tests and the hematoma size, there was a positive significant correlation between serum creatinine and size of hematoma among all cases (r = 0.576, P < 0.001); the same relation is present between serum urea and size of hematoma. On the other hand there was a negative significant association between estimated GFR (creatinine clearance) and hematoma size (r = −0.362, P < 0.005) [Table 2], [Figure 1] and [Figure 2].
|Figure 1: Correlation between serum creatinine (Creat.) and size of hematoma (P < 0. 05).|
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|Figure 2: Correlation between estimated GFR (Creat. clearance) and size of hematoma (P < 0.05). Creat., creatinine; GFR, glomerular filtration rate.|
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As regard the ICH score, there was a positive significant correlation between serum creatinine and ICH score among all cases (r = 0.525, P < 0.001); on the other hand there was a negative significant correlation between estimated GFR (creatinine clearance) and ICH score among all cases (r = −0.593, P < 0.001) [Table 3], [Figure 3] and [Figure 4].
|Figure 3: Correlation between serum creatinine and intracerebral hemorrhage (ICH) score (P < 0.05). Creat., creatinine.|
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|Figure 4: Correlation between estimated GFR (Creat. clearance) and intracerebral hemorrhage (ICH) score (P < 0.05). Creat., creatinine; GFR, glomerular filtration rate.|
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| Discussion|| |
Renal dysfunction has been shown to be associated with adverse outcome in numerous vaso-occlusive diseases. In ischemic stroke, reduced estimated GFR was associated with higher in-hospital mortality . In addition; creatinine clearance was a predictor of short-term and long-term mortality in ischemic stroke . In our study, it was found that estimated GFR has a negative correlation with the ICH score and hence it affects the mortality rate of such castes. Our results are consistent with other reports. For example reduced renal function (estimated GFR < 60 ml/min/1.73 m 2 ) was found to be an independent predictor of the combined endpoint of death or disability at 12 months in patients with hemorrhagic stroke .
In a series of consecutive patients presented by ICH excluding those with chronic kidney disease, Ovbiagele et al.  found that renal dysfunction (admission estimated GFR < 60 ml/min/1.73 m 2 ) was associated with reduced likelihood of discharge directly to home versus discharge to a skilled nursing facility, inpatient rehabilitation, or to a service for a higher level of care. However, when adjusted for confounding factors, the difference was not statistically significant, which the authors attributed to the study being underpowered for multivariate analysis. Another study reported that patients with an estimated GFR less than 45 ml/min/1.73 m 2 had a four-fold adjusted hazard ratio increase for mortality versus patients with estimated GFR more than 60 ml/min/1.73 m 2 over the course of 1 year . This study also reported that the median hematoma volume was significantly higher in the group with estimated GFR less than 45 ml/min/1.73 m 2 than in the group with estimated GFR more than 60 ml/min/1.73 m 2 , while Rhoney et al.  reported that the worse the renal function, the larger the ICH volume provided that estimated GFR is less than 90 ml/min/1.73 m 2 .
This latter finding is consistent with the negative correlation between ICH volume and estimated GFR that we observed and may offer insight into the association between renal dysfunction and mortality. Specifically, increased bleeding may be related to platelet dysfunction associated with decreased estimated GFR. Another possibility is that hematoma growth is provoked by kidney disease-associated induction of inflammation signaling, for example, matrix metalloproteinase expression. Matrix metalloproteinases can degrade basal laminae and disrupt the blood-brain barrier; both factors contribute to hematoma growth and hemorrhagic transformation of ischemic lesions. A third possibility is that kidney dysfunction affects other aspects of coagulation in addition to platelet function .
However, in our study a cutoff point of estimated GFR could not be identified for a significant correlation with both the size of hematoma and the ICH score like the previously mentioned studies. This may be due to the small sample size used in this study. In addition, we used Cockcroft-Gault equation to calculate the estimated GFR while other studies depended on the Modification of Diet in Renal Disease (MDRD) equation.
The glomerulus is a high-pressure filtration system, composed of a specialized capillary network. It generates an ultrafiltrate that is free of blood and significant amounts of blood proteins. Renal damage or alterations in glomerular function affect the kidneys' ability to remove metabolic substances from the blood into the urine . GFR is the rate (volume per unit of time) at which ultrafiltrate is formed by the glomerulus. Approximately 120 ml is formed per minute. The GFR is a direct measure of renal function. It is reduced before the onset of symptoms of renal failure and is related to the severity of the structural abnormalities in chronic renal disease. As it is not easy to measure the GFR directly, the serum creatinine concentration is often used to assess renal function. Creatinine clearance provides a more accurate assessment and can be calculated from the serum creatinine or more exactly from the results of a 24 h urine collection. Creatinine clearance can be measured as an indicator of GFR. In adults, two main equations have been used: the Cockcroft and Gault equation and the MDRD equation .
Cockcroft-Gault equation is widely used particularly in the context of assessing drug dosages for patients with kidney impairment. In addition to several theoretical objections to use of this equation, the requirement for measurement of body weight has been a major practical impediment to the use of the equation in wider clinical practice. On the other hand, the MDRD equation is more suitable for use in black Africans-Americans, and there is no requirement for patient weight .
Our limitation of this study included use of small sample size, absence of follow-up cohorts for a defined period of time and the presence of confounding factors that may affect the findings; so the results of this study may be more applicable on short term.
| Conclusion|| |
Renal dysfunction was an independent predictor of initial in-hospital mortality after ICH; this may be due to increasing the size of hematoma; hence assessment of renal functions may stratify risk in such patients.
The author gratefully acknowledges several colleagues and technicians in the Laboratory of King Abdulaziz Hospital, Mecca, Saudi Arabia for their help and technical support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bar B, Hemphill JC. Charlson comorbidity index adjustment in intracerebral hemorrhage. Stroke 2011; 42
Godoy DA, Piñero G, Di Napoli M. Predicting mortality in spontaneous intracerebral hemorrhage: can modification to original score improve the prediction? Stroke 2006; 37
Hansen BM, Nilsson OG, Anderson H, Norrving B, Säveland H, Lindgren A. Long term (13 years) prognosis after primary intracerebral haemorrhage: a prospective population based study of long term mortality, prognostic factors and causes of death. J Neurol Neurosurg Psychiatry 2013; 84
González-Pérez A, Gaist D, Wallander MA, McFeat G, García-Rodríguez LA. Mortality after hemorrhagic stroke: data from general practice (The Health Improvement Network). Neurology 2013; 81
Cheung RT, Zou LY, Cheung RT, Zou LY, Rainer TH, Wong LK, et al
. Use of the original, modified, or new intracerebral hemorrhage score to predict mortality and morbidity after intracerebral hemorrhage. Stroke 2003; 34
Hemphill JC, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke 2001; 32
Muir KW, Weir CJ, Murray GD, Povey C, Lees KR. Comparison of neurological scales and scoring systems for acute stroke prognosis. Stroke 1996; 27
Hemphill JC, Farrant M, Neill TA Jr. Prospective validation of the ICH Score for 12-month functional outcome. Neurology 2009; 73
Parry-Jones AR, Abid KA, Di Napoli M, Smith CJ, Vail A, Patel HC, et al.
Accuracy and clinical usefulness of intracerebral hemorrhage grading scores: a direct comparison in a UK population. Stroke 2013; 44
Yahalom G, Schwartz R, Schwammenthal Y, Merzeliak O, Toashi M, Orion D, et al.
Chronic kidney disease and clinical outcome in patients with acute stroke. Stroke 2009; 40
Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron 1976; 16
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
Molshatzki N, Orion D, Tsabari R, Schwammenthal Y, Merzeliak O, Toashi M, Tanne D. Chronic kidney disease in patients with acute intracerebral hemorrhage: association with large hematoma volume and poor outcome. Cerebrovasc Dis 2011; 31
Hao Z, Wu B, Lin S, Kong FY, Tao WD, Wang DR, Liu M Association between renal function and clinical outcome in patients with acute stroke. Eur Neurol 2010; 63
Ovbiagele B, Pineda S, Saver JL. Renal dysfunction and discharge destination in patients with intracerebral hemorrhage. J Stroke Cerebrovasc Dis 2011; 20
Rhoney DH, Parker D Jr, Millis Sr, Whittaker P. Kidney dysfunction at the time of intracerebral hemorrhage is associated with increased in-hospital mortality: a retrospective observational cohort study. Neurol Res 2012; 34
Nankivell BJ. Creatinine clearance and the assessment of renal function. Aust Prescr 2001; 24
Lamb EJ, Price CP. Kidney function tests. In: Burtis CA, Ashwood ER, Bruns DE, eds. Tietz textbook of clinical chemistry and molecular diagnostics
. New York: Elsevier Saunders; 2012. 696.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]