J Korean Neurosurg Soc.  2017 Nov;60(6):620-626. 10.3340/jkns.2016.1010.009.

Elevated Blood Urea Nitrogen/Creatinine Ratio Is Associated with Venous Thromboembolism in Patients with Acute Ischemic Stroke

• Kim H
• Lee K
• Choi HA
• Samuel S
• Park JH
• Jo KW

• KMID: 2395780
• DOI: http://doi.org/10.3340/jkns.2016.1010.009

Abstract

OBJECTIVE
Although venous thromboembolism (VTE) is frequently related to dehydration, the impact of dehydration on VTE in acute ischemic stroke (AIS) is not clear. This study investigated whether dehydration, as measured by blood urea nitrogen (BUN)/creatinine (Cr) ratio, influences the occurrence of VTE in patients with AIS.
METHODS
This is a retrospective study of patients with AIS between January 2012 and December 2013. Patients with newly diagnosed AIS who experienced prolonged hospitalization for at least 4 weeks were included in this study.
RESULTS
Of 182 patients included in this study, 17 (9.3%) suffered VTE during the follow-up period; in two cases, VTE was accompanied by deep vein thrombosis and pulmonary embolism. Patients with VTE were more frequently female and had higher National Institutes of Health Stroke Scale (NIHSS) score, more lower limb weakness, and elevated blood urea nitrogen BUN/Cr ratio on admission. In a multivariate analysis, BUN/Cr ratio >15 (odds ratio [OR] 8.75) and severe lower limb weakness (OR 4.38) were independent risk factors for VTE.
CONCLUSION
Dehydration on admission in cases of AIS might be a significant independent risk factor for VTE.

Keyword

Blood urea nitrogen; Creatinine; Venous thrombosis; Dehydration; Cerebral infarction

MeSH Terms

Blood Urea Nitrogen
Cerebral Infarction
Creatinine
Dehydration
Female
Follow-Up Studies
Hospitalization
Humans
Lower Extremity
Multivariate Analysis
National Institutes of Health (U.S.)
Pulmonary Embolism
Retrospective Studies
Risk Factors
Stroke*
Urea*
Venous Thromboembolism*
Venous Thrombosis
Creatinine
Urea

Figure

• 

  Fig. 1 Representative box plot showing the distribution of BUN/Cr ratio between non-VTE and VTE groups. BUN: blood urea nitrogen, Cr: creatinine, VTE: venous thromboembolism.

Reference

References

1. Agrawal M, Swartz R. Acute renal failure. Am Fam Physician. 61:2077–2088. 2000.

2. Anderson FA Jr, Spencer FA. Risk factors for venous thromboembolism. Circulation. 107(23 Suppl 1):I9–I16. 2003.

3. Ansell JE. Air travel and venous thromboembolism--is the evidence in? N Engl J Med. 345:828–829. 2001.

4. Bembenek J, Karlinski M, Kobayashi A, Czlonkowska A. Early stroke-related deep venous thrombosis: risk factors and influence on outcome. J Thromb Thrombolysis. 32:96–102. 2011.

5. Bennett JA, Thomas V, Riegel B. Unrecognized chronic dehydration in older adults: examining prevalence rate and risk factors. J Gerontol Nurs. 30:22–28. quiz 52–53. 2004.

6. Bhalla A, Sankaralingam S, Dundas R, Swaminathan R, Wolfe CD, Rudd AG. Influence of raised plasma osmolality on clinical outcome after acute stroke. Stroke. 31:2043–2048. 2000.

7. Bhatia K, Mohanty S, Tripathi BK, Gupta B, Mittal MK. Predictors of early neurological deterioration in patients with acute ischaemic stroke with special reference to blood urea nitrogen (BUN)/creatinine ratio & urine specific gravity. Indian J Med Res. 141:299–307. 2015.

8. Bounds JV, Wiebers DO, Whisnant JP, Okazaki H. Mechanisms and timing of deaths from cerebral infarction. Stroke. 12:474–477. 1981.

9. Broderick JP, Palesch YY, Demchuk AM, Yeatts SD, Khatri P, Hill MD, et al. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med. 368:893–903. 2013.

10. CLOTS Trials Collaboration. Dennis M, Sandercock PA, Reid J, Graham C, Murray G, et al. Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial. Lancet. 373:1958–1965. 2009.

11. Goldman RD, Friedman JN, Parkin PC. Validation of the clinical dehydration scale for children with acute gastroenteritis. Pediatrics. 122:545–549. 2008.

12. González-Alonso J, Calbet JA, Nielsen B. Muscle blood flow is reduced with dehydration during prolonged exercise in humans. J Physiol. 513(Pt 3):895–905. 1998.

13. Harvey RL. Prevention of venous thromboembolism after stroke. Top Stroke Rehabil. 10:61–69. 2003.

14. Hull RD. Revisiting the past strengthens the present: an evidence-based medicine approach for the diagnosis of deep venous thrombosis. Ann Intern Med. 142:583–585. 2005.

15. Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 44:870–947. 2013.

16. Kelly J, Rudd A, Lewis RR, Coshall C, Moody A, Hunt BJ. Venous thromboembolism after acute ischemic stroke: a prospective study using magnetic resonance direct thrombus imaging. Stroke. 35:2320–2325. 2004.

17. Kelly J, Rudd A, Lewis RR, Coshall C, Parmar K, Moody A, et al. Screening for proximal deep vein thrombosis after acute ischemic stroke: a prospective study using clinical factors and plasma D-dimers. J Thromb Haemost. 2:1321–1326. 2004.

18. Landi G, D’Angelo A, Boccardi E, Candelise L, Mannucci PM, Morabito A, et al. Venous thromboembolism in acute stroke. Prognostic importance of hypercoagulability. Arch Neurol. 49:279–283. 1992.

19. Leibovitz A, Baumoehl Y, Lubart E, Yaina A, Platinovitz N, Segal R. Dehydration among long-term care elderly patients with oropharyngeal dysphagia. Gerontology. 53:179–183. 2007.

20. Liu CH, Lin SC, Lin JR, Yang JT, Chang YJ, Chang CH, et al. Dehydration is an independent predictor of discharge outcome and admission cost in acute ischaemic stroke. Eur J Neurol. 21:1184–1191. 2014.

21. Marik PE, Andrews L, Maini B. The incidence of deep venous thrombosis in ICU patients. Chest. 111:661–664. 1997.

22. Noel P, Gregoire F, Capon A, Lehert P. Atrial fibrillation as a risk factor for deep venous thrombosis and pulmonary emboli in stroke patients. Stroke. 22:760–762. 1991.

23. O’Neill PA, Davies I, Fullerton KJ, Bennett D. Fluid balance in elderly patients following acute stroke. Age Ageing. 21:280–285. 1992.

24. Oczkowski WJ, Ginsberg JS, Shin A, Panju A. Venous thromboembolism in patients undergoing rehabilitation for stroke. Arch Phys Med Rehabil. 73:712–716. 1992.

25. Pottier P, Hardouin JB, Lejeune S, Jolliet P, Gillet B, Planchon B. Immobilization and the risk of venous thromboembolism. A meta-analysis on epidemiological studies. Thromb Res. 124:468–476. 2009.

26. Riccardi A, Chiarbonello B, Minuto P, Guiddo G, Corti L, Lerza R. Identification of the hydration state in emergency patients: correlation between caval index and BUN/creatinine ratio. Eur Rev Med Pharmacol Sci. 17:1800–1803. 2013.

27. Rønning OM, Guldvog B. Stroke unit versus general medical wards, II: neurological deficits and activities of daily living: a quasi-randomized controlled trial. Stroke. 29:586–590. 1998.

28. Rowat A, Graham C, Dennis M. Dehydration in hospital-admitted stroke patients: detection, frequency, and association. Stroke. 43:857–859. 2012.

29. Schrock JW, Glasenapp M, Drogell K. Elevated blood urea nitrogen/creatinine ratio is associated with poor outcome in patients with ischemic stroke. Clin Neurol Neurosurg. 114:881–884. 2012.

30. Skaf E, Stein PD, Beemath A, Sanchez J, Bustamante MA, Olson RE. Venous thromboembolism in patients with ischemic and hemorrhagic stroke. Am J Cardiol. 96:1731–1733. 2005.

31. Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated? JAMA. 291:2746–2754. 2004.

32. Sulter G, De Keyser J. From stroke unit care to stroke care unit. J Neurol Sci. 162:1–5. 1999.

33. Turpie AG, Levine MN, Hirsh J, Carter CJ, Jay RM, Powers PJ, et al. Double-blind randomised trial of Org 10172 low-molecular-weight heparinoid in prevention of deep-vein thrombosis in thrombotic stroke. Lancet. 1:523–526. 1987.

34. Vega RM, Avner JR. A prospective study of the usefulness of clinical and laboratory parameters for predicting percentage of dehydration in children. Pediatr Emerg Care. 13:179–182. 1997.

35. Virchow R. Thrombose und embolie. Gefässentzündung und septische infektion. Virchow R, editor. Gesammelte abhandlungen zur wissenschaftlichen medicin. Frankfurt: Verlag von Meidinger Sohn & Comp;1856. p. 219–732.

36. White RH, Zhou H, Romano PS. Incidence of idiopathic deep venous thrombosis and secondary thromboembolism among ethnic groups in California. Ann Intern Med. 128:737–740. 1998.

37. Yilmaz K, Karaböcüoglu M, Citak A, Uzel N. Evaluation of laboratory tests in dehydrated children with acute gastroenteritis. J Paediatr Child Health. 38:226–228. 2002.