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The impact of chronic kidney disease on prognosis in acute stroke: unraveling the pathophysiology and clinical complexity for optimal management

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Abstract

Background

Chronic kidney disease (CKD) significantly increases stroke risk and severity, posing challenges in both acute management and long-term outcomes. CKD contributes to cerebrovascular pathology through systemic inflammation, oxidative stress, endothelial dysfunction, vascular calcification, impaired cerebral autoregulation, and a prothrombotic state, all of which exacerbate stroke risk and outcomes.

Methods

This review synthesizes evidence from peer-reviewed literature to elucidate the pathophysiological mechanisms linking CKD and stroke. It evaluates the efficacy and safety of acute reperfusion therapies—intravenous thrombolysis and endovascular thrombectomy—in CKD patients with acute ischemic stroke. Considerations, such as renal function, drug dosage adjustments, and the risk of contrast-induced nephropathy, are critically analyzed. Evidence-based recommendations and research priorities are drawn from an analysis of current practices and existing knowledge gaps.

Results

CKD influences stroke outcomes through systemic and local pathophysiological changes, necessitating tailored therapeutic approaches. Reperfusion therapies are effective in CKD patients but require careful monitoring of renal function to mitigate risks, such as contrast-induced nephropathy and thrombolytic complications. The bidirectional relationship between stroke and CKD highlights the need for integrated management strategies to address both conditions. Early detection and optimized management of CKD significantly reduce stroke-related morbidity and mortality.

Conclusion

Optimizing stroke care in CKD patients requires a comprehensive understanding of their pathophysiology and clinical management challenges. This article provides evidence-based recommendations, emphasizing individualized treatment decisions and coordinated care. It underscores the importance of integrating renal considerations into stroke treatment protocols and highlights the need for future research to refine therapeutic strategies, address knowledge gaps, and consider tailored interventions to improve outcomes and quality of life for this high-risk population.

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Data availability

The original contributions presented in the study are included in the article, and further inquiries can be directed to the corresponding author.

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Acknowledgements

The author acknowledges the financial support received from the Grant-in-Aid for Scientific Research (KAKENHI) (PI: SMMB) by the Japan Society for the Promotion of Science (JSPS), Japanese Ministry of Education, Culture, Sports, Science, and Technology (MEXT). Additionally, we extend our gratitude for the JSPS International Fellowship, supported by MEXT and the Australian Academy of Science, awarded to SMMB for 2023-25. SMMB reports leadership or fiduciary roles in various organizations, including the National Cerebral and Cardiovascular Center (Osaka, Japan) as Visiting Director (2023-25); Rotary District 9675 as District Chair for Diversity, Equity, and Inclusion; the Global Health and Migration Hub Community, Global Health Hub Germany (Berlin, Germany) as Chair, Founding Member, and Manager; and editorial board memberships at PLOS One, BMC Neurology, Frontiers in Neurology, Frontiers in Stroke, Frontiers in Public Health, Journal of Aging Research, and BMC Medical Research Methodology. Additionally, SMMB serves as a Member of the College of Reviewers for the Canadian Institutes of Health Research (CIHR), Government of Canada; Director of Research for the World Headache Society (Bengaluru, India); a member of the Scientific Review Committee at Cardiff University Biobank (Cardiff, UK); and as an Expert Adviser/Reviewer for the Cariplo Foundation (Milan, Italy); outside the submitted work. The funding body has no role in the study design, data collection, analysis, interpretation of findings, and manuscript preparation. The content is solely the authors' responsibility and does not necessarily represent the official views of the affiliated/funding organization/s.

Funding

The author acknowledges the financial support received from the Grant-in-Aid for Scientific Research (KAKENHI) (PI: SMMB) by the Japan Society for the Promotion of Science (JSPS), Japanese Ministry of Education, Culture, Sports, Science, and Technology (MEXT). Additionally, we extend our gratitude to the JSPS International Fellowship, supported by MEXT, and the Australian Academy of Science, awarded to SMMB for the period 2023–25.

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Author notes

  1. Sonu M. M. Bhaskar

    Present address: National Cerebral and Cardiovascular Center (NCVC), Department of Neurology, Division of Cerebrovascular Medicine and Neurology, Suita, Osaka, 564-8565, Japan

Authors and Affiliations

  1. Global Health Neurology Lab, Sydney, NSW, 2150, Australia

    Kruthajn Rajesh, Vedant Upmanyue, Roy G. Beran & Sonu M. M. Bhaskar

  2. UNSW Medicine and Health, University of New South Wales (UNSW), South West Sydney Clinical Campuses, Sydney, NSW 2F170, Australia

    Kruthajn Rajesh, Vedant Upmanyue, Roy G. Beran & Sonu M. M. Bhaskar

  3. NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW, 2170, Australia

    Kevin J. Spring, Roy G. Beran & Sonu M. M. Bhaskar

  4. Medical Oncology Group, Ingham Institute for Applied Medical Research, Sydney, NSW, 2751, Australia

    Kevin J. Spring

  5. School of Medicine, Western Sydney University, Sydney, NSW, 2000, Australia

    Kevin J. Spring & Roy G. Beran

  6. Diabetes and Metabolic Disorders Skopje, Faculty of Medical Sciences, University Clinic of Endocrinology, The Goce Delčev University of Štip, Štip, North Macedonia

    Ivica Smokovski

  7. Department of Neurology, BLK Super Speciality Hospital, New Delhi, India

    Man Mohan Mehndiratta

  8. Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia

    Giovanni F. M. Strippoli

  9. Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari “Aldo Moro”, 70124, Bari, Italy

    Giovanni F. M. Strippoli

  10. Griffith Health, School of Medicine and Dentistry, Griffith University, Southport, QLD, 4215, Australia

    Roy G. Beran

  11. Department of Neurology & Neurophysiology, Liverpool Hospital and South West Sydney Local Health District, Liverpool, NSW, 2170, Australia

    Roy G. Beran & Sonu M. M. Bhaskar

Authors
  1. Kruthajn Rajesh
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  2. Kevin J. Spring
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  3. Ivica Smokovski
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  8. Sonu M. M. Bhaskar
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Contributions

SMMB conceived the study, contributed to the manuscript's planning, drafting, and revision, and supervised the students (KR and VU). SMMB encouraged KR to investigate and supervised the findings of this work. KR and SMMB wrote the first draft of this paper. All authors (KJ, KJS, IS, VP, MMM, GFMS, RGB, and SMMB) critically evaluated the draft and contributed to the revision of the manuscript. All authors approved the final draft of the manuscript.

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Correspondence to Sonu M. M. Bhaskar.

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Rajesh, K., Spring, K.J., Smokovski, I. et al. The impact of chronic kidney disease on prognosis in acute stroke: unraveling the pathophysiology and clinical complexity for optimal management. Clin Exp Nephrol 29, 149–172 (2025). https://doi.org/10.1007/s10157-024-02556-w

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