AccScience Publishing / AN / Online First / DOI: 10.36922/AN025220065
Submit to AN
Cite this article
2
Download
72
Views
Journal Browser
Volume | Year
Issue
Search
Forthcoming Issue
Current Issue
View All
News and Announcements
View All
ORIGINAL RESEARCH ARTICLE

Clinical, laboratory, and neuroimaging features and management of ischemic brain infarctions associated with uremic syndrome in chronic kidney disease

Sherifa A. Hamed1* ,  Samir K. Abdulhamid2 ,  Ali Farrag Elhadad3 ,  Ehab Mansour Mohamed Moussa4
Show Less
1 Department of Neurology and Psychiatry, Assiut University Hospital, Assiut, Egypt
2 Department of Internal Medicine, Assiut University Hospital, Assiut, Egypt
3 Department of Neuropsychiatry, Faculty of Medicine, Al Azhar University, Assiut, Egypt
4 Department of Diagnostic Radiology, Faculty of Medicine, Assiut University, Assiut, Egypt
Advanced Neurology, 025220065 https://doi.org/10.36922/AN025220065
Received: 27 May 2025 | Revised: 23 August 2025 | Accepted: 3 September 2025 | Published online: 16 October 2025
© 2025 by the Author(s). This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution 4.0 International License ( https://creativecommons.org/licenses/by/4.0/ )
Download PDF
XML
Cite
Abstract

Research on cerebrovascular stroke and its predictors in chronic kidney disease (CKD) patients is limited compared to cardiovascular studies. In this study, we aimed to investigate the frequency, types, risk factors, and symptoms of ischemic brain infarctions in CKD patients. This observational study involved 155 adults with CKD, with an average age of 55.36 ± 4.28 years; 70 were males and 85 were females. The mean duration of uremia was 6.40 ± 1.36 years. Among the included patients, 71% were receiving hemodialysis. All participants underwent neurological assessment, laboratory testing, carotid duplex ultrasonography, and brain magnetic resonance imaging. The prevalence of silent ischemic brain infarctions was high at 78.7% (n = 122), with a higher occurrence among end-stage kidney disease patients (n = 110) compared to those not on dialysis (p=0.0001). About 19.7% (n = 24) developed focal stroke symptoms, while 63.2% (n = 98) were asymptomatic. Neurological symptoms included dysarthria, hemihypoesthesia, hemianopia, parkinsonism, and choreo-dystonia. Regression analysis revealed that brain infarctions were linked to severity of CKD (odds ratio [OR] = 6.32, 95% confidence interval [CI] = 3.20–15.45, p=0.0001), hypertension (OR = 8.34, 95% CI = 5.46–16.25, p=0.0001), hypertriglyceridemia (OR = 5.20, 95% CI = 2.45–12.33, p=0.001), hyperuricemia (OR = 3.40, 95% CI = 1.40–6.32, p=0.001), anemia (OR = 2.43, 95% CI = 1.60–5.28, p=0.01), hypoalbuminemia (OR = 3.25, 95% CI = 1.64–8.42, p=0.01), and albuminuria (OR = 2.53, 95% CI = 1.20–5.42, p=0.03). Persistent brain damage led to poor clinical outcomes in stroke patients. In conclusion, CKD patients face an elevated risk of ischemic brain infarctions and stroke, with various vascular and non-vascular risk factors playing a role. Management strategies should focus on correcting metabolic abnormalities, addressing underdiagnosed risk factors, and implementing preventive measures to reduce the risk of recurrent strokes.

Keywords
Chronic kidney disease
Uremia
Ischemic brain infarctions
Cerebrovascular stroke
Funding
None.
Conflict of interest
The authors declare that they have no competing interests.
References
  1. Coresh J, Selvin E, Stevens LA, et al. Prevalence of chronic kidney disease in the United States. JAMA. 2007;298(17):2038-2047. doi: 10.1001/jama.298.17.2038

 

  1. Meyer TW, Hostetter TH. Uremia. N Engl J Med. 2007;357(13):1316-1325. doi: 10.1056/NEJMra071313

 

  1. Tonelli M, Karumanchi SA, Thadhani R. Epidemiology and mechanisms of uremia-related cardiovascular disease. Circulation. 2016;133(5):518-536. doi: 10.1161/CIRCULATIONAHA.115.018713

 

  1. Toyoda K, Ninomiya T. Stroke and cerebrovascular diseases in patients with chronic kidney disease. Lancet Neurol. 2014;13(8):823-833. doi: 10.1016/S1474-4422(14)70026-2

 

  1. Zimmerman D, Sood MM, Rigatto C, Holden RM, Hiremath S, Clase CM. Systematic review and meta-analysis of incidence, prevalence and outcomes of atrial fibrillation in patients on dialysis. Nephrol Dial Transplant. 2012;27(10):3816-3822. doi: 10.1093/ndt/gfs416

 

  1. Teza H, Boonmanunt S, Unwanatham N, et al. Evaluation of transitions from early hypertension to hypertensive chronic kidney disease, coronary artery disease, stroke and mortality: A Thai real-world data cohort. Front Cardiovasc Med. 2023;10:1170010. doi: 10.3389/fcvm.2023.1170010

 

  1. Gherghina ME, Peride I, Tiglis M, Neagu TP, Niculae A, Checherita IA. Uric acid and oxidative stress-relationship with cardiovascular, metabolic, and renal impairment. Int J Mol Sci. 2022;23(6):3188. doi: 10.3390/ijms23063188

 

  1. Yen CL, Fan PC, Lee CC, et al. Association of low-density lipoprotein cholesterol levels during statin treatment with cardiovascular and renal outcomes in patients with moderate chronic kidney disease. J Am Heart Assoc. 2022;11(19):e027516. doi: 10.1161/JAHA.122.027516

 

  1. Barsoum RS. Chronic kidney disease in the developing world. N Engl J Med. 2006;354(10):997-999. doi: 10.1056/NEJMp058318

 

  1. Hamed S, Mohamed K, Abd Elhameed S, et al. Movement disorders due to selective basal ganglia lesions with uremia. Can J Neurol Sci. 2020;47(3):350-365. doi: 10.1017/cjn.2020.29

 

  1. Shima H, Ishimura E, Naganuma T, et al. Decreased kidney function is a significant factor associated with silent cerebral infarction and periventricular hyperintensities. Kidney Blood Press Res. 2011;34(6):430-438. doi: 10.1159/000328722

 

  1. Masson P, Webster AC, Hong M, Turner R, Lindley RI, Craig JC. Chronic kidney disease and the risk of stroke: A systematic review and meta-analysis. Nephrol Dial Transplant. 2015;30(7):1162-1169. doi: 10.1093/ndt/gfv009

 

  1. Shima H, Ishimura E, Naganuma T, et al. Cerebral microbleeds in predialysis patients with chronic kidney disease. Nephrol Dial Transplant. 2010;25(5):1554-1559. doi: 10.1093/ndt/gfp694

 

  1. El Husseini N, Fonarow GC, Smith EE, et al. Renal dysfunction is associated with poststroke discharge disposition and in-hospital mortality: Findings from get with the guidelines-stroke. Stroke. 2017;48(2):327-334. doi: 10.1161/STROKEAHA.116.014601

 

  1. Rizikalo A, Coric S, Matetic A, Vasilj M, Tocilj Z, Bozic J. Association of glomerular filtration rate and carotid intima-media thickness in non-diabetic chronic kidney disease patients over a 4-year follow-up. Life (Basel). 2021;11(3):204. doi: 10.3390/life11030204

 

  1. Makin SD, Cook FA, Dennis MS, Wardlaw JM. Cerebral small vessel disease and renal function: Systematic review and meta-analysis. Cerebrovasc Dis. 2015;39(1):39-52. doi: 10.1159/000369777

 

  1. Agarwal A, Cheung AK, Ma J, Cho M, Li M. Effect of baseline kidney function on the risk of recurrent stroke and on effects of intensive blood pressure control in patients with previous lacunar stroke: A post hoc analysis of the SPS3 trial (secondary prevention of small subcortical strokes). J Am Heart Assoc. 2019;8(16):e013098. doi: 10.1161/JAHA.119.013098

 

  1. Sozio SM, Armstrong PA, Coresh J, et al. Cerebrovascular disease incidence, characteristics, and outcomes in patients initiating dialysis: The choices for healthy outcomes in caring for ESRD (CHOICE) study. Am J Kidney Dis. 2009;54(3):468-477. doi: 10.1053/j.ajkd.2009.01.261

 

  1. Hamed SA. Neurologic conditions and disorders in uremic syndrome of chronic kidney disease: Presentations, causes and treatment strategies Expert Rev Clin Pharmacol. 2019;12(1):61-90. doi: 10.1080/17512433.2019.1555468

 

  1. National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification, and stratification. Am J Kidney Dis. 2002;39(2 Suppl 1):S1-266.

 

  1. Hamed SA, Abdulhamid SK, ElHadad AF, Fawzy M, Abd- ElHamed MA. Restless leg syndrome in patients with chronic kidney disease: A Hospital-based study from Upper Egypt. Int J Neurosci. 2023;133(3):257-268. doi: 10.1080/00207454.2021.1910256

 

  1. Hamed SA, Hamed EA, Hamdy R, Nabeshima T. Vascular risk factors and oxidative stress as independent predictors of asymptomatic atherosclerosis in Adult patients with epilepsy. Epilepsy Res. 2007;74(2-3):183-192. doi: 10.1016/j.jstrokecerebrovasdis.2009.04.007

 

  1. Liu Y, Lv P, Jin H, et al. Association between low estimated glomerular filtration rate and risk of cerebral small-vessel diseases: A meta-analysis. J Stroke Cerebrovasc Dis. 2016;25(3):710-716. doi: 10.1016/j.jstrokecerebrovasdis.2015.11.016

 

  1. Kobayashi M, Hirawa N, Yatsu K, et al. Relationship between silent brain infarction and chronic kidney disease. Nephrol Dial Transplant. 2009;24(1):201-207. doi: 10.1093/ndt/gfn419

 

  1. Chou CC, Lien LM, Chen WH, et al. Adults with late stage 3 chronic kidney disease are at high risk for prevalent silent brain infarction: A population-based study. Stroke. 2011;42(8):2120-2125. doi: 10.1161/STROKEAHA.110.597930

 

  1. Kim SH, Shin DW, Yun JM, et al. Kidney dysfunction and silent brain infarction in generally healthy adults. J Neurol Sci. 2017;379:89-93. doi: 10.1016/j.jns.2017.05.043

 

  1. Ikram MA, Vernooij MW, Hofman A, Niessen WJ, van der Lugt A, Breteler MM. Kidney function is related to cerebral small vessel disease. Stroke. 2008;39(1):55-61. doi: 10.1161/STROKEAHA.107.493494

 

  1. Debette S, Markus HS. The clinical importance of white matter hyperintensities on brain magnetic resonance imaging: Systematic review and meta-analysis. BMJ. 2010;341:c3666. doi: 10.1136/bmj.c3666

 

  1. Sharma R, Sekhon S, Lui F, Cascella M. White matter lesions. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2025. Available from: https://www.ncbi.nlm.nih.gov/books/ NBK562167 [Last accessed on 2025 Feb 10].

 

  1. Vermeer SE, Hollander M, van Dijk EJ, et al. Silent brain infarcts and white matter lesions increase stroke risk in the general population: The Rotterdam Scan Study. Stroke. 2003;34(5):1126-1129. doi: 10.1161/01.STR.0000068408.82115.D2

 

  1. Khatri M, Wright CB, Nickolas TL, et al. Chronic kidney disease is associated with white matter hyperintensity volume: The Northern Manhattan Study (NOMAS). Stroke. 2007;38(12):3121-3126. doi: 10.1161/STROKEAHA.107.493593

 

  1. Gaziano L, Sun L, Arnold M, et al. Mild-to-moderate kidney dysfunction and cardiovascular disease: Observational and Mendelian randomization analyses. Circulation. 2022;146(20):1507-1517. doi: 10.1161/CIRCULATIONAHA.122.060700

 

  1. Ito S, Nagasawa T, Abe M, Mori T. Strain vessel hypothesis: A viewpoint for linkage of albuminuria and cerebro-cardiovascular risk. Hypertens Res. 2009;32(2):115-121. doi: 10.1038/hr.2008.27

 

  1. Johnson RJ, Feehally J, Floege J. Comprehensive Clinical Nephrology. 5th ed. Philadelphia, PA: Elsevier Health Sciences; 2014.

 

  1. Romero JR, Beiser A, Seshadri S, et al. Carotid artery atherosclerosis, MRI indices of brain ischemia, aging, and cognitive impairment: The Framingham study. Stroke. 2009;40(5):1590-1596. doi: 10.1161/STROKEAHA.108.535245

 

  1. Agarwal R. Pathogenesis of diabetic nephropathy. In: Chronic Kidney Disease and Type 2 Diabetes. Arlington, VA: American Diabetes Association; 2021. Available from: https://www.ncbi.nlm.nih.gov/books/NBK571720 [Last accessed on 2025 Feb 10]. doi: 10.2337/db20211-2

 

  1. Poznyak A, Grechko AV, Poggio P, Myasoedova VA, Alfieri V, Orekhov AN. The diabetes mellitus-atherosclerosis connection: The role of lipid and glucose metabolism and chronic inflammation. Int J Mol Sci. 2020;21(5):1835. doi: 10.3390/ijms21051835

 

  1. Pelisek J, Assadian A, Sarkar O, Eckstein HH, Frank H. Carotid plaque composition in chronic kidney disease: A retrospective analysis of patients undergoing carotid endarterectomy. Eur J Vasc Endovasc Surg. 2010;39(1):11-16. doi: 10.1016/j.ejvs.2009.09.024

 

  1. Holzer M, Birner-Gruenberger R, Stojakovic T, et al. Uremia alters HDL composition and function. J Am Soc Nephrol. 2011;22(9):1631-1641. doi: 10.1681/ASN.2010111144

 

  1. Piani F, Sasai F, Bjornstad P, et al. Hyperuricemia and chronic kidney disease: To treat or not to treat. J Bras Nefrol. 2021;43(4):572-579. doi: 10.1590/2175-8239-JBN-2020-U002

 

  1. Yu ZF, Bruce-Keller AJ, Goodman Y, Mattson MP. Uric acid protects neurons against excitotoxic and metabolic insults in cell culture, and against focal ischemic brain injury in vivo. J Neurosci Res. 1998;53(5):613-625. doi: 10.1002/(SICI)1097-4547(19980901)53:5<613:AID-JNR11>3.0.CO;2-1

 

  1. Hayden MR, Tyagi SC. Uric acid: A new look at an old risk marker for cardiovascular disease, metabolic syndrome, and type 2 diabetes mellitus: The urate redox shuttle. Nutr Metab (Lond). 2004;1(1):10. doi: 10.1186/1743-7075-1-10

 

  1. Abramson JL, Jurkovitz CT, Vaccarino V, Weintraub WS, McClellan W. Chronic kidney disease, anemia, and incident stroke in a middle-aged, community-based population: The ARIC Study. Kidney Int. 2003;64(2):610-615. doi: 10.1046/j.1523-1755.2003.00109.x

 

  1. Hashmi MF, Shaikh H, Rout P. Anemia of chronic kidney disease. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2025. Available from: https://www.ncbi.nlm.nih. gov/books/NBK539871 [Last accessed on 2025 Feb 10].

 

  1. Lee M, Saver JL, Chang KH, Liao HW, Chang SC, Ovbiagele B. Impact of microalbuminuria on incident stroke: A meta-analysis. Stroke. 2010;41(11):2625-2631. doi: 10.1161/STROKEAHA.110.581215

 

  1. Nakatani T, Naganuma T, Uchida J, et al. Silent cerebral infarction in hemodialysis patients. Am J Nephrol. 2003;23(2):86-90. doi: 10.1159/000068034

 

  1. Kuller LH, Eichner JE, Orchard TJ, Grandits GA, McCallum L, Tracy RP. The relation between serum albumin levels and risk of coronary heart disease in the Multiple Risk Factor Intervention Trial. Am J Epidemiol. 1991;134(11):1266-1277. doi: 10.1093/oxfordjournals.aje.a116030

 

  1. Power A, Chan K, Singh SK, Taube D, Duncan N. Appraising stroke risk in maintenance hemodialysis patients: A large single-center cohort study. Am J Kidney Dis. 2012;59(2):249-257. doi: 10.1053/j.ajkd.2011.07.016

 

  1. Wakasugi M, Yokoseki A, Wada M, et al. Stroke incidence and chronic kidney disease: A hospital-based prospective cohort study. Nephrology (Carlton). 2022;27(7):577-587. doi: 10.1111/nep.14049

 

  1. Jungers P, Nguyen Khoa T, Massy ZA, et al. Incidence of atherosclerotic arterial occlusive accidents in predialysis and dialysis patients: A multicentric study in the Ile de France district. Nephrol Dial Transplant. 1999;14(4):898-902. doi: 10.1093/ndt/14.4.898

 

  1. Wang HC, Hsu JL, Shen YY. Acute bilateral basal ganglia lesions in patients with diabetic uremia: An FDG-PET study. Clin Nucl Med. 2004;29(8):475-478. doi: 10.1097/01.rlu.0000132881.83830.f7

 

  1. Li JY, Yong TY, Sebben R, Khoo E, Disney AP. Bilateral basal ganglia lesions in patients with end-stage diabetic nephropathy. Nephrology (Carlton). 2008;13(1):68-72. doi: 10.1111/j.1440-1797.2007.00838.x

 

  1. Kim TK, Seo SI, Kim JH, Lee NJ, Seol HY. Diffusion-weighted magnetic resonance imaging in the syndrome of acute bilateral basal ganglia lesions in diabetic uremia. Mov Disord. 2006;21(8):1267-1270. doi: 10.1002/mds.20932

 

  1. Park JH, Kim HJ, Kim SM. Acute chorea with bilateral basal ganglia lesions in diabetic uremia. Can J Neurol Sci. 2007;34(2):248-250. doi: 10.1017/s0317167100006144

 

  1. Kiryluk K, Khan F, Valeri A. Acute chorea and bilateral basal ganglia lesions in a hemodialysis patient. Kidney Int. 2008;73(9):1087-1091. doi: 10.1038/sj.ki.5002768

 

  1. Renard D, Castelnovo G, Taieb G, Verd A, Lionnet C, Labauge P. Bilateral basal ganglia lesions in a diabetic-uremic patient with dystonia. Acta Neurol Belg. 2011;111(2):166-167.

 

  1. Addi T, Dou L, Burtey S. Tryptophan-derived uremic toxins and thrombosis in chronic kidney disease. Toxins (Basel). 2018;10(10):412. doi: 10.3390/toxins10100412

 

  1. Boutitie F, Oprisiu R, Achard JM, et al. Does a change in angiotensin II formation caused by antihypertensive drugs affect the risk of stroke? A meta-analysis of trials according to treatment with potentially different effects on angiotensin II. J Hypertens. 2007;25(8):1543-1553. doi: 10.1097/HJH.0b013e32814a5ae5

 

  1. Padda IS, Mahtani AU, Parmar M. Sodium-glucose transport protein 2 (SGLT2) inhibitors. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2025. Available from: https:// www.ncbi.nlm.nih.gov/books/NBK576405 [Last accessed on 2025 Feb 10].

 

  1. Crea F. Dyslipidaemias in stroke, chronic kidney disease, and aortic stenosis: The new frontiers for cholesterol lowering. Eur Heart J. 2021;42(22):2137-2140. doi: 10.1093/eurheartj/ehab295

 

  1. Kielstein JT, Pontremoli R, Burnier M. Management of hyperuricemia in patients with chronic kidney disease: A focus on renal protection. Curr Hypertens Rep. 2020;22(12):102. doi: 10.1007/s11906-020-01116-3

 

  1. Dad T, Weiner DE. Stroke and chronic kidney disease: Epidemiology, pathogenesis, and management across kidney disease stages. Semin Nephrol. 2015;35(4):311-322. doi: 10.1016/j.semnephrol.2015.06.003

 

  1. Jung JM, Kim HJ, Ahn H, et al. Chronic kidney disease and intravenous thrombolysis in acute stroke: A systematic review and meta-analysis. J Neurol Sci. 2015;358(1-2):345-350. doi: 10.1016/j.jns.2015.09.353

 

  1. Sutherland LJ, Diprose WK, Wang MTM, Barber PA. Chronic kidney disease and outcome following endovascular thrombectomy for acute ischemic stroke. J Stroke Cerebrovasc Dis. 2020;29(4):104665. doi: 10.1016/j.jstrokecerebrovasdis.2020.104665

 

  1. Sood MM, Larkina M, Thumma JR, et al. Major bleeding events and risk stratification of antithrombotic agents in hemodialysis: Results from the DOPPS. Kidney Int. 2013;84(3):600-608. doi: 10.1038/ki.2013.170

 

  1. Rhee TM, Lee SR, Choi EK, Oh S, Lip GYH. Efficacy and safety of oral anticoagulants for atrial fibrillation patients with chronic kidney disease: A systematic review and meta-analysis. Front Cardiovasc Med. 2022;9:885548. doi: 10.3389/fcvm.2022.885548

 

  1. Polinder-Bos HA, García DV, Kuipers J, et al. Hemodialysis induces an acute decline in cerebral blood flow in elderly patients. J Am Soc Nephrol. 2018;29(4):1317-1325. doi: 10.1681/ASN.2017101088

 

  1. Israni RK, Kasbekar N, Haynes K, Berns JS. Use of antiepileptic drugs in patients with kidney disease. Semin Dial. 2006;19(5):408-416. doi: 10.1111/j.1525-139X.2006.00195.x

 

  1. Hamed SA, Abdulhamid SK, El Hadad AF. Uremic seizures with chronic kidney disease: Types causes and treatments. J Neurol Exp Neurosci. 2020;6(2):58-65. doi: 10.17756/jnen.2020-076
Next article in this issue
Share
Back to top
Advanced Neurology, Electronic ISSN: 2810-9619 Print ISSN: 3060-8589, Published by AccScience Publishing
We use cookies on our website to ensure you get the best experience.
Read more about our cookies here
Accept