Balancing Blood Pressure After Endovascular Thrombectomy: Risks of Acute Kidney Injury and Impact on Stroke Recovery

Highlight

• Intensive systolic blood pressure (BP) lowering (<140 mm Hg) after successful endovascular thrombectomy significantly increases the risk of acute kidney injury (AKI) compared to conventional BP targets (140-180 mm Hg).

• Most AKI events observed were mild (stage 1), yet they were associated with markedly worse neurological outcomes, including lower functional independence and higher mortality at 3 months.

• AKI after thrombectomy represents a marker of systemic hemodynamic vulnerability and indicates the need for cautious post-procedure BP management.

Study Background

Acute ischemic stroke due to large-vessel occlusion is a major cause of disability and death worldwide. Endovascular thrombectomy (EVT) has become the standard of care for eligible patients, substantially improving recanalization rates and functional outcomes. However, optimal management of blood pressure (BP) after successful EVT remains controversial. While elevated BP may increase the risk of hemorrhagic transformation, overly aggressive BP lowering could potentially impair organ perfusion, including the kidneys, predispose to AKI, and affect recovery.

AKI is a well-recognized complication in critically ill patients and is associated with worse short- and long-term outcomes. However, its incidence and implications in the context of post-thrombectomy BP management have been insufficiently studied. The OPTIMAL-BP trial sought to clarify the risks and benefits of intensive versus conventional BP targets in this patient population, with a secondary analysis focusing on AKI occurrence and its impact on functional outcomes.

Study Design

This secondary analysis included 287 patients from the OPTIMAL-BP randomized trial who had acute ischemic stroke from large-vessel occlusion and underwent successful EVT. Eligible patients had systolic BP ≥140 mm Hg at enrollment. Participants were randomized to intensive BP management targeting systolic BP <140 mm Hg or conventional BP management targeting systolic BP 140-180 mm Hg for 24 hours post-procedure.

AKI was evaluated within two time frames: early AKI within 2 days and AKI within 7 days post-thrombectomy, defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Functional independence was assessed at 3 months, defined as modified Rankin Scale (mRS) scores of 0 to 2. Multivariable logistic regression analyses adjusted for age, sex, time from stroke onset to enrollment, baseline NIH Stroke Scale score, and baseline estimated glomerular filtration rate (eGFR) were employed to determine associations.

Key Findings

AKI within 7 days occurred in 13.6% of patients in the intensive BP group versus 6.4% in the conventional group, yielding an adjusted odds ratio (OR) of 2.54 (95% CI, 1.10–6.35), demonstrating a statistically significant increased risk with intensive BP lowering. Early AKI within 2 days was also more frequent in the intensive group, although the sensitivity analysis balancing creatinine ascertainment did not reach statistical significance but showed a consistent trend.

The majority (69%) of AKI cases were mild (stage 1), and none progressed to severe renal failure requiring dialysis within the observation period. Nonetheless, AKI presence was strongly associated with adverse clinical outcomes: patients with AKI had significantly lower odds of functional independence at 3 months (adjusted OR 0.19; 95% CI, 0.05–0.55) and a markedly increased risk of stroke-related mortality (adjusted OR 13.8; 95% CI, 4.14–49.64).

These findings emphasize that—even mild post-EVT kidney injury—has important prognostic implications. Patients experiencing AKI may represent a subgroup with greater systemic hemodynamic vulnerability or impaired autoregulatory mechanisms in the context of aggressive BP reduction.

Expert Commentary

This analysis sheds light on a critical but underexplored consequence of intensive BP management after EVT. The kidneys, as highly perfusion-dependent organs, may be particularly susceptible to hemodynamic fluctuations caused by rapid or excessive BP control in the acute stroke setting.

Clinical guidelines currently lack consensus on optimal BP targets post-EVT, largely due to balancing the prevention of hemorrhagic transformation and ensuring adequate cerebral and systemic perfusion. These results suggest that overly aggressive BP lowering strategies increase AKI risk, which is linked to poor neurological recovery and survival.

Study limitations include secondary analysis nature, limited sample size for evaluating severe AKI, and potential confounders despite adjustment. Nevertheless, the findings encourage a cautious, individualized approach to BP control, integrating renal function monitoring and hemodynamic stability assessment.

Further research is required to elucidate the mechanistic pathways linking BP modulation, renal vulnerability, and brain recovery after ischemic stroke, and to establish tailored BP management protocols to optimize both neurologic and renal outcomes.

Conclusion

This secondary analysis of the OPTIMAL-BP trial demonstrates that intensive BP lowering (<140 mm Hg systolic) following successful endovascular thrombectomy increases the incidence of acute kidney injury, predominantly mild in severity. Importantly, AKI is strongly associated with poorer functional outcomes and increased mortality at 3 months in stroke patients.

These findings highlight the importance of balancing cerebral protection against systemic organ perfusion during post-thrombectomy management. Clinicians should be vigilant regarding renal function when implementing intensive BP control and consider individual hemodynamic tolerance. Optimizing BP targets post-EVT remains an unmet clinical need requiring further prospective studies.

Funding and Clinical Trials Registry

This study was funded and conducted as part of the OPTIMAL-BP trial, registered at ClinicalTrials.gov (Identifier: NCT04205305).

References

• Jung JW, Koh HB, Kim YD, et al. Acute Kidney Injury After Intensive Blood Pressure Lowering Following Successful Endovascular Thrombectomy. Stroke. 2026 Jul 24. PMID: 42495732.

• Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl. 2012;2(1):1-138.

• Goyal M, Menon BK, van Zwam WH, et al; HERMES collaborators. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387(10029):1723-1731.

• Qureshi AI, Palesch YY, Barsan WG, et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. N Engl J Med. 2016;375(11):1033-1043.