Should a patient with end-stage renal disease (ESRD) on dialysis who experiences a cerebrovascular accident (CVA) be excluded from tissue plasminogen activator (tPA) use?

Dialysis Patients and tPA Use in Acute Ischemic Stroke

Dialysis is NOT an absolute contraindication to tPA administration in acute ischemic stroke, but these patients require careful risk-benefit assessment and should generally be offered tPA within the standard 3-4.5 hour window if they meet eligibility criteria. 1

Guideline Position on Dialysis as a Contraindication

The major stroke guidelines do not list end-stage renal disease (ESRD) or dialysis dependence as absolute contraindications to intravenous tPA. 1 The ACEP/AAN clinical policies from 2013 and 2015 extensively reviewed tPA safety and efficacy data, and while they discuss numerous exclusion criteria, dialysis status is notably absent from the contraindication lists. 1

Patients with ESRD on dialysis who present with acute ischemic stroke within 3 hours of symptom onset should be offered tPA after shared decision-making discussion about risks and benefits. 1 For the 3-4.5 hour window, the same recommendation applies with appropriate patient selection. 1

Critical Considerations Specific to Dialysis Patients

Elevated Baseline Stroke Risk

• Dialysis patients have a 38% incidence of stroke events occurring during or within 12 hours after hemodialysis sessions, representing a period of particularly elevated ischemic risk. 2
• The periprocedural nature of many strokes in this population (occurring during HD) does not change tPA eligibility if the patient otherwise meets criteria. 2

Coagulation Abnormalities

• ESRD patients demonstrate complex hemostatic derangements including reduced functional activities of factors XII, IX, X, and II despite normal or elevated antigen levels. 3
• They exhibit hyperfibrinogenemia, elevated D-dimer, reduced antithrombin III, and decreased free protein S concentrations. 3
• These laboratory abnormalities do not constitute contraindications to tPA but should inform the risk-benefit discussion. 3

Hemorrhagic Risk Assessment

• While dialysis patients have altered coagulation profiles, the standard symptomatic intracranial hemorrhage rate with tPA (4-6%) applies unless other specific contraindications exist. 1, 4
• The presence of uremic platelet dysfunction does not automatically exclude tPA use but warrants careful consideration. 3

Practical Clinical Algorithm

1. Confirm acute ischemic stroke diagnosis with non-contrast head CT to exclude hemorrhage. 1, 4

2. Document time of symptom onset and last dialysis session timing. 2

3. Assess standard tPA eligibility criteria - dialysis status alone does not exclude the patient. 1

4. Check for actual contraindications:

   • Active anticoagulation (including DOACs - see below)
   • Recent surgery or bleeding
   • Uncontrolled hypertension
   • Other standard exclusions 1

5. Obtain CT angiogram to identify large vessel occlusion for potential mechanical thrombectomy. 5, 4

6. Engage in shared decision-making discussing the 4-6% symptomatic ICH risk and potential benefits. 1, 4

7. If within 3-4.5 hour window and no contraindications exist, administer tPA at standard dosing (0.9 mg/kg, maximum 90 mg). 1

Critical Pitfalls to Avoid

Do not reflexively exclude dialysis patients from tPA based solely on their renal status. 1 This represents a common error that denies potentially beneficial therapy.

Do not administer tPA if the patient is on direct oral anticoagulants (DOACs) regardless of dialysis status - this is an actual contraindication until validated DOAC level testing is available. 1, 4

Do not delay mechanical thrombectomy consultation while deciding about tPA - these patients may be excellent thrombectomy candidates even if tPA is deferred. 5, 4

Avoid attributing neurologic changes during or after dialysis solely to metabolic causes - nearly one-quarter of dialysis patients with stroke have symptom onset during the HD session itself. 2

Special Circumstance: Anticoagulation Status

If the dialysis patient is on warfarin, heparin, or DOACs, standard anticoagulation-related tPA contraindications apply regardless of dialysis status. 1, 4 For patients on DOACs specifically, tPA should not be administered, but mechanical thrombectomy remains an option. 1, 4

Post-tPA Management

After tPA administration, delay aspirin therapy until the 24-hour post-thrombolysis scan excludes intracranial hemorrhage. 1 Then initiate aspirin 81-325 mg daily as standard acute stroke care. 1