Beyond the Threshold: Continuous Creatinine Change and Outcomes After Endovascular Thrombectomy for Acute Ischemic Stroke.
Contrast-associated acute kidney injury (CA-AKI) after endovascular thrombectomy (EVT) worsens outcomes in acute ischemic stroke, but threshold-based definitions do not capture prognostic information from subthreshold changes. We tested whether early creatinine change within 48 hours of EVT conveys graded prognostic information beyond dichotomous CA-AKI.
We performed a secondary analysis of the CAN-REST (Contrast-Associated Nephropathy After Endovascular Stroke Treatment; REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT06596603) registry, a retrospective multicenter observational cohort study of 6638 EVT-treated adults with acute ischemic stroke enrolled at 73 centers in 16 countries between January 1 and December 31, 2023. Early creatinine change was quantified as the natural logarithm ratio of 48-hour creatinine to baseline creatinine (ln[48-hour/baseline creatinine]), with CA-AKI defined per Kidney Disease: Improving Global Outcomes criteria (≥0.3 mg/dL or ≥1.5× baseline rise within 48 hours). Multivariable logistic regression adjusted for prespecified baseline and periprocedural covariates examined associations with 90-day modified Rankin Scale shift and in-hospital mortality; linear versus restricted cubic spline specification was selected by likelihood ratio testing, and contrasts were estimated at ±10%, ±25%, and ±50%.
Greater creatinine worsening within 48 hours of EVT was independently associated with an unfavorable 90-day modified Rankin Scale shift (adjusted common odds ratio per 1-unit log-ratio increase, 1.48 [95% CI, 1.07-2.04]; linear) and in-hospital mortality (nonlinear dose-response, of larger magnitude). A 10% increase in creatinine at 48 hours-well below Kidney Disease: Improving Global Outcomes threshold-was associated with worse functional outcome (adjusted common odds ratio, 1.04 [95% CI, 1.01-1.07]) and death (adjusted odds ratio, 1.22 [95% CI, 1.13-1.32]); a 10% decrease in creatinine at 48 hours was associated with lower odds of both outcomes (adjusted common odds ratio, 0.96 [95% CI, 0.93-0.99] and 0.74 [95% CI, 0.65-0.86]). The functional-outcome association concentrated at upper modified Rankin Scale cut-points (severe disability, death); effect modification by baseline renal function was not significant.
Early creatinine change after EVT conveys graded, outcome-specific prognostic information extending below formal CA-AKI thresholds, with a dose-response detectable at changes as modest as ±10%, complementing binary CA-AKI as a framework for post-EVT renal risk assessment.
URL: https://www.clinicaltrials.gov; Unique identifier: NCT06596603.
We performed a secondary analysis of the CAN-REST (Contrast-Associated Nephropathy After Endovascular Stroke Treatment; REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT06596603) registry, a retrospective multicenter observational cohort study of 6638 EVT-treated adults with acute ischemic stroke enrolled at 73 centers in 16 countries between January 1 and December 31, 2023. Early creatinine change was quantified as the natural logarithm ratio of 48-hour creatinine to baseline creatinine (ln[48-hour/baseline creatinine]), with CA-AKI defined per Kidney Disease: Improving Global Outcomes criteria (≥0.3 mg/dL or ≥1.5× baseline rise within 48 hours). Multivariable logistic regression adjusted for prespecified baseline and periprocedural covariates examined associations with 90-day modified Rankin Scale shift and in-hospital mortality; linear versus restricted cubic spline specification was selected by likelihood ratio testing, and contrasts were estimated at ±10%, ±25%, and ±50%.
Greater creatinine worsening within 48 hours of EVT was independently associated with an unfavorable 90-day modified Rankin Scale shift (adjusted common odds ratio per 1-unit log-ratio increase, 1.48 [95% CI, 1.07-2.04]; linear) and in-hospital mortality (nonlinear dose-response, of larger magnitude). A 10% increase in creatinine at 48 hours-well below Kidney Disease: Improving Global Outcomes threshold-was associated with worse functional outcome (adjusted common odds ratio, 1.04 [95% CI, 1.01-1.07]) and death (adjusted odds ratio, 1.22 [95% CI, 1.13-1.32]); a 10% decrease in creatinine at 48 hours was associated with lower odds of both outcomes (adjusted common odds ratio, 0.96 [95% CI, 0.93-0.99] and 0.74 [95% CI, 0.65-0.86]). The functional-outcome association concentrated at upper modified Rankin Scale cut-points (severe disability, death); effect modification by baseline renal function was not significant.
Early creatinine change after EVT conveys graded, outcome-specific prognostic information extending below formal CA-AKI thresholds, with a dose-response detectable at changes as modest as ±10%, complementing binary CA-AKI as a framework for post-EVT renal risk assessment.
URL: https://www.clinicaltrials.gov; Unique identifier: NCT06596603.
Authors
Schwarz Schwarz, Cascio Rizzo Cascio Rizzo, Ambler Ambler, Wrona Wrona, Slowik Slowik, Bodzioch Bodzioch, Doheim Doheim, Al-Bayati Al-Bayati, Nogueira Nogueira, Nunes Nunes, Ferreira Ferreira, Paolucci Paolucci, Zini Zini, Simonetti Simonetti, Leško Leško, Fedorko Fedorko, Gdovinová Gdovinová, Scarcia Scarcia, Kalsoum Kalsoum, Farhat Farhat, Beyeler Beyeler, Mujanovic Mujanovic, Arnold Arnold, Meira Meira, Morais Morais, Francisco Francisco, WiÄ…cek WiÄ…cek, PudĹ‚o PudĹ‚o, Bartosik-Psujek Bartosik-Psujek, Calleja Calleja, Ostos Ostos, Seoane Seoane, Anca Anca, Radu Radu, Tiu Tiu, Al Kasab Al Kasab, Abu Qdais Abu Qdais, Samman Tahhan Samman Tahhan, Ayo-Martin Ayo-Martin, Hernández-Fernández Hernández-Fernández, Paya Paya, Molina-Nevo Molina-Nevo, Labuz-Roszak Labuz-Roszak, Toni Toni, Moszko Moszko, Roszak Roszak, De Michele De Michele, Barrile Barrile, Eswaradass Eswaradass, Houghton Houghton, Barkley Barkley, Ali Ali, Demeestere Demeestere, Bauknight Bauknight, Sheth Sheth, Maes Maes, Wouters Wouters, Marto Marto, Costa Costa, Loizzo Loizzo, Romi Romi, Currò Currò, Luchowski Luchowski, Seweryn Seweryn, Rejdak Rejdak, Klein Klein, Abdalkader Abdalkader, Saia Saia, Sanna Sanna, Tassinari Tassinari, Acampa Acampa, Rosini Rosini, Tassi Tassi, Bilik Bilik, Bandzarewicz-Samcik Bandzarewicz-Samcik, Min Min, HajAissa HajAissa, Mangiardi Mangiardi, Anticoli Anticoli, Pampana Pampana, Hervás-Testal Hervás-Testal, Rigual Rigual, Fuentes Fuentes, Strambo Strambo, Tetaria Tetaria, Saliou Saliou, Caramma Caramma, Maimone Maimone, Rizzo Rizzo, Moci Moci, Scala Scala, Cruz-Culebras Cruz-Culebras, Vera Lechuga Vera Lechuga, Garcia Madrona Garcia Madrona, Merlino Merlino, Valente Valente, Todesco Todesco, Bolognese Bolognese, Lakatos Lakatos, Karwacki Karwacki, Candelaresi Candelaresi, Andreone Andreone, Maurea Maurea, Tarletti Tarletti, Mele Mele, Ciacciarelli Ciacciarelli, Alessiani Alessiani, Monteforte Monteforte, Pakizer Pakizer, Roubec Roubec, Ĺ koloudĂk Ĺ koloudĂk, Vandervorst Vandervorst, De Raedt De Raedt, Verdam Verdam, Bartoš Bartoš, Ĺ rámek Ĺ rámek, Mazzoleni Mazzoleni, Quilici Quilici, Alimonti Alimonti, Moller Moller, Maestrini Maestrini, Diomedi Diomedi, Lacidogna Lacidogna, Zaidat Zaidat, Lin Lin, AlMajali AlMajali, Baracchini Baracchini, Zaccagnino Zaccagnino, Viaro Viaro, Pezzini Pezzini, Avola Avola, Ferraro Ferraro, ĹšwitoĹ„ska ĹšwitoĹ„ska, Sobieszak-Skura Sobieszak-Skura, Meder Meder, Mayer-Suess Mayer-Suess, Knoflach Knoflach, Gizewski Gizewski, Common Common, Nicholson Nicholson, Power Power, Nowakowska-Kotas Nowakowska-Kotas, Pula Pula, Guzinski Guzinski, PĂ©rez Sánchez PĂ©rez Sánchez, Montaner Montaner, Sevilla Bravo Sevilla Bravo, Marcheselli Marcheselli, Vodret Vodret, Rapillo Rapillo, Pereira Pereira, Rodrigues Rodrigues, Jaros Jaros, Kovar Kovar, Vojik Vojik, Valcamonica Valcamonica, Gallo Cassarino Gallo Cassarino, Cardillo Cardillo, Petruzzellis Petruzzellis, Grimaldi Grimaldi, Marrone Marrone, Hassan Hassan, Miller Miller, Khasawneh Khasawneh, Poretto Poretto, Tonello Tonello, Tollot Tollot, DÄ™biec DÄ™biec, Staszewski Staszewski, Stepien Stepien, Bernardo Bernardo, Ferrao Ferrao, Zedde Zedde, Pascarella Pascarella, Sanna Sanna, Meloni Meloni, Delibas Delibas, Sacco Sacco, Vittorini Vittorini, Ornello Ornello, Mannino Mannino, Terruso Terruso, Filizzolo Filizzolo, Hall Hall, Roffe Roffe, Dorobek Dorobek, Zielinska-Turek Zielinska-Turek, Scopelliti Scopelliti, Pantoni Pantoni, Pero Pero, Macera Macera, Cervo Cervo, Bellavia Bellavia, Longoni Longoni, Sezgin Sezgin, Dilmen Dilmen, Ekizoglu Ekizoglu, Tsivgoulis Tsivgoulis, Theodorou Theodorou, Tiu Tiu, Panea Panea, Petrescu Petrescu, Piano Piano, Nguyen Nguyen, Sessa Sessa
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