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정재욱Jae Wook Jung
연세대학교 의과대학
Stroke, Jul 24 2026, | https://doi.org/10.1161/STROKEAHA.126.056127
Acute Kidney Injury After Intensive Blood Pressure Lowering Following Successful Endovascular Thrombectomy
Jae Wook Jung # 1, Hee Byung Koh # 2, Young Dae Kim 1, JoonNyung Heo 1, Hyungwoo Lee 1, Byung Moon Kim 3, Dong Joon Kim 3, Na-Young Shin 3, Sungwook Yu 4, Seong Hwan Ahn 5, Sung-Il Sohn 6, Jeong-Ho Hong 6, Tae-Jin Song 7, Yoonkyung Chang 8, Gyu Sik Kim 9, Taedong Ok 9, Jun Young Chang 10, Jung Hwa Seo 11, Sukyoon Lee 12, Jang-Hyun Baek 13, Han-Jin Cho 14, Jaeseob Yun 14, Dong Hoon Shin 15, Sang Hee Ha 15, Jinkwon Kim 16, Joonsang Yoo 16, Minyoul Baik 16, Yo Han Jung 17, Kwon-Duk Seo 18, Yang-Ha Hwang 19, Hyungjong Park 19, Chi Kyung Kim 20, Jae Guk Kim 21, Il Hyung Lee 22, Jin Kyo Choi 23, Soyoung Jeon 24, Hye Sun Lee 24, Kwang Hyun Kim 25, Sun U Kwon 10, Oh Young Bang 26, Ji Hoe Heo 27, Hyo Suk Nam 1; OPTIMAL-BP trial investigators
1Department of Neurology (J.W.J., Y.D.K., J.N.H., H.L., H.S.N.), Yonsei University College of Medicine, Seoul, Korea.
2Department of Nephrology (H.B.K.), Yonsei University College of Medicine, Seoul, Korea.
3Department of Radiology (B.M.K., D.J.K., N.-Y.S.), Yonsei University College of Medicine, Seoul, Korea.
4Department of Neurology, Korea University Anam Hospital and College of Medicine, Seoul, Korea (S.Y.).
5Department of Neurology, Chosun University School of Medicine, Gwangju, Korea (S.H.A.).
6Department of Neurology, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea (S.-I.S., J.-H.H.).
7Department of Neurology, Seoul Hospital, Ewha Woman's University, College of Medicine, Korea (T.-J.S.).
8Department of Neurology, Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Korea (Y.C.).
9National Health Insurance Service Ilsan Hospital, Goyang, Korea (G.S.K., T.O.).
10Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (J.Y.C., S.U.K.).
11Department of Neurology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, South Korea (J.H.S.).
12Department of Neurology, Busan Paik Hospital, Inje University College of Medicine, South Korea (S.L.).
13Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (J.-H.B.).
14Department of Neurology, Pusan National University School of Medicine, Busan, Korea (H.-J.C., J. Yun).
15Department of Neurology, Gachon University Gil Medical Center, Incheon, Korea (D.H.S., S.H.H.).
16Department of Neurology, Yongin Severance Hospital, Yonsei University College of Medicine, Korea (J.K., J. Yoo, M.B.).
17Department of Neurology (Y.H.J.), Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
18Department of Radiology (K.-D.S.), Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
19Department of Neurology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea (Y.-H.H., H.P.).
20Department of Neurology, Korea University Guro Hospital and College of Medicine, Seoul, Korea (C.K.K.).
21Department of Neurology, Daejeon Eulji Medical Center, Eulji University School of Medicine, Korea (J.G.K.).
22Department of Neurology, Kyung Hee University Hospital at Gangdong, Seoul, Korea (I.H.L.).
23Department of Neurology, Seoul Medical Center, Seoul, Korea (J.K.C.).
24Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea (S.J., H.S.L.).
25Department of Neurology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea (K.H.K.).
26Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (O.Y.B.).
27Department of Neurology, CHA Bundang Medical Center, CHA University, Seongnam, Korea (J.H.H.).
#Contributed equally.
Correspondence to: Hyo Suk Nam, MD, PhD
1Department of Neurology (J.W.J., Y.D.K., J.N.H., H.L., H.S.N.), Yonsei University College of Medicine, Seoul, Korea.
2Department of Nephrology (H.B.K.), Yonsei University College of Medicine, Seoul, Korea.
3Department of Radiology (B.M.K., D.J.K., N.-Y.S.), Yonsei University College of Medicine, Seoul, Korea.
4Department of Neurology, Korea University Anam Hospital and College of Medicine, Seoul, Korea (S.Y.).
5Department of Neurology, Chosun University School of Medicine, Gwangju, Korea (S.H.A.).
6Department of Neurology, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea (S.-I.S., J.-H.H.).
7Department of Neurology, Seoul Hospital, Ewha Woman's University, College of Medicine, Korea (T.-J.S.).
8Department of Neurology, Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Korea (Y.C.).
9National Health Insurance Service Ilsan Hospital, Goyang, Korea (G.S.K., T.O.).
10Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (J.Y.C., S.U.K.).
11Department of Neurology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, South Korea (J.H.S.).
12Department of Neurology, Busan Paik Hospital, Inje University College of Medicine, South Korea (S.L.).
13Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (J.-H.B.).
14Department of Neurology, Pusan National University School of Medicine, Busan, Korea (H.-J.C., J. Yun).
15Department of Neurology, Gachon University Gil Medical Center, Incheon, Korea (D.H.S., S.H.H.).
16Department of Neurology, Yongin Severance Hospital, Yonsei University College of Medicine, Korea (J.K., J. Yoo, M.B.).
17Department of Neurology (Y.H.J.), Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
18Department of Radiology (K.-D.S.), Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
19Department of Neurology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea (Y.-H.H., H.P.).
20Department of Neurology, Korea University Guro Hospital and College of Medicine, Seoul, Korea (C.K.K.).
21Department of Neurology, Daejeon Eulji Medical Center, Eulji University School of Medicine, Korea (J.G.K.).
22Department of Neurology, Kyung Hee University Hospital at Gangdong, Seoul, Korea (I.H.L.).
23Department of Neurology, Seoul Medical Center, Seoul, Korea (J.K.C.).
24Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea (S.J., H.S.L.).
25Department of Neurology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea (K.H.K.).
26Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (O.Y.B.).
27Department of Neurology, CHA Bundang Medical Center, CHA University, Seongnam, Korea (J.H.H.).
#Contributed equally.
Correspondence to: Hyo Suk Nam, MD, PhD
Abstract
Background: The effect of postthrombectomy blood pressure (BP) management on the development of acute kidney injury (AKI) in patients with acute ischemic stroke remains largely unexplored.
Methods: This secondary analysis of the OPTIMAL-BP trial (Outcome in Patients Treated With Intra-Arterial Thrombectomy-Optimal Blood Pressure Control) included patients with acute ischemic stroke due to large-vessel occlusion who achieved successful endovascular thrombectomy and had a systolic BP ≥140 mm Hg. Patients were randomized to intensive (target systolic BP <140 mm Hg) or conventional (target systolic BP 140-180 mm Hg) BP management for 24 hours. The outcomes were AKI within 7 days and within 2 days, defined according to the Kidney Disease: Improving Global Outcomes criteria. In addition, we examined the associations between AKI and functional independence at 3 months, defined as a modified Rankin Scale score of 0 to 2. Multivariable logistic regression analyses were performed with adjustment for age, sex, time from stroke onset to enrollment, baseline National Institutes of Health Stroke Scale score, and baseline estimated glomerular filtration rate.
Results: Of 306 patients, 19 were excluded, and 287 patients were included in this analysis (mean age, 73.2 years; 117 [40.8%] women). AKI within 7 days occurred more frequently in the intensive management group than in the conventional group (20/147 [13.6%] versus 9/140 [6.4%]; adjusted odds ratio, 2.54 [95% CI, 1.10-6.35]). Most AKI events were stage 1 (20/29 [69.0%]). Early AKI within 2 days was also more common with intensive BP management. Patients with AKI had significantly lower rates of functional independence (4/29 [13.8%] versus 126/257 [49.0%]; adjusted odds ratio, 0.19 [95% CI, 0.05-0.55]) and higher stroke-related mortality at 3 months (11/29 [37.9%] versus 8/257 [3.1%]; adjusted odds ratio, 13.8 [95% CI, 4.14-49.64]). In a sensitivity analysis with equal creatinine ascertainment, the association with 48-hour AKI did not reach statistical significance (7/76 [9.2%] versus 2/66 [3.0%]; adjusted odds ratio, 4.20 [95% CI, 0.83-32.6]), although the absolute risk difference remained directionally consistent.
Conclusions: Intensive BP lowering after successful endovascular thrombectomy was associated with a higher risk of AKI, even when kidney injury was predominantly mild. In addition, AKI was associated with worse neurological outcomes. These findings suggest that AKI is an important marker of systemic hemodynamic vulnerability after aggressive postendovascular thrombectomy BP lowering.
Methods: This secondary analysis of the OPTIMAL-BP trial (Outcome in Patients Treated With Intra-Arterial Thrombectomy-Optimal Blood Pressure Control) included patients with acute ischemic stroke due to large-vessel occlusion who achieved successful endovascular thrombectomy and had a systolic BP ≥140 mm Hg. Patients were randomized to intensive (target systolic BP <140 mm Hg) or conventional (target systolic BP 140-180 mm Hg) BP management for 24 hours. The outcomes were AKI within 7 days and within 2 days, defined according to the Kidney Disease: Improving Global Outcomes criteria. In addition, we examined the associations between AKI and functional independence at 3 months, defined as a modified Rankin Scale score of 0 to 2. Multivariable logistic regression analyses were performed with adjustment for age, sex, time from stroke onset to enrollment, baseline National Institutes of Health Stroke Scale score, and baseline estimated glomerular filtration rate.
Results: Of 306 patients, 19 were excluded, and 287 patients were included in this analysis (mean age, 73.2 years; 117 [40.8%] women). AKI within 7 days occurred more frequently in the intensive management group than in the conventional group (20/147 [13.6%] versus 9/140 [6.4%]; adjusted odds ratio, 2.54 [95% CI, 1.10-6.35]). Most AKI events were stage 1 (20/29 [69.0%]). Early AKI within 2 days was also more common with intensive BP management. Patients with AKI had significantly lower rates of functional independence (4/29 [13.8%] versus 126/257 [49.0%]; adjusted odds ratio, 0.19 [95% CI, 0.05-0.55]) and higher stroke-related mortality at 3 months (11/29 [37.9%] versus 8/257 [3.1%]; adjusted odds ratio, 13.8 [95% CI, 4.14-49.64]). In a sensitivity analysis with equal creatinine ascertainment, the association with 48-hour AKI did not reach statistical significance (7/76 [9.2%] versus 2/66 [3.0%]; adjusted odds ratio, 4.20 [95% CI, 0.83-32.6]), although the absolute risk difference remained directionally consistent.
Conclusions: Intensive BP lowering after successful endovascular thrombectomy was associated with a higher risk of AKI, even when kidney injury was predominantly mild. In addition, AKI was associated with worse neurological outcomes. These findings suggest that AKI is an important marker of systemic hemodynamic vulnerability after aggressive postendovascular thrombectomy BP lowering.
논문소개전체 설명
제목 : 혈전제거술 후 적극적인 혈압강하가 급성 신장 기능 손상을 증가시킬 수 있음을 규명
논문 소개 :
급성 허혈성 뇌졸중에서 혈관내 혈전제거술(endovascular thrombectomy, EVT)은 막힌 뇌혈관을 신속하게 재개통시키는 표준 치료이다. 그러나 재관류 이후 혈압을 어느 수준까지 낮추는 것이 가장 적절한지는 오랫동안 논란이 되어 왔다. 최근 여러 무작위 임상시험에서 과도한 혈압강하가 오히려 환자의 예후를 악화시킬 수 있다는 결과가 보고되었지만, 그 기전에 대해서는 충분히 밝혀지지 않았다.
본 연구는 국내 19개 뇌졸중센터에서 교신저자 주도로 수행된 OPTIMAL-BP 무작위 임상시험 자료를 이용하여, 혈전제거술 후 적극적인 혈압조절(수축기혈압 <140 mmHg)이 신장 기능에 미치는 영향을 분석하였다. 연구 결과, 적극적인 혈압강하군은 표준 혈압조절군보다 급성 신손상(acute kidney injury, AKI) 발생 위험이 약 2.5배 높았으며, 대부분 경증(Stage 1)이었음에도 불구하고 AKI가 발생한 환자에서는 3개월 후 기능적 독립성이 크게 감소하였고 사망률은 현저히 증가하였다. 또한 평균 혈압보다 일시적인 저혈압과 혈압 저하의 정도 및 지속시간이 AKI와 밀접하게 연관됨을 확인하였다.
본 연구의 가장 큰 의의는 혈전제거술 후 혈압조절의 문제를 기존의 ‘뇌 관류 유지’라는 관점에서 한 단계 확장하여, ‘신장을 포함한 전신 장기 보호’라는 새로운 개념을 제시했다는 점이다. 즉, 과도한 혈압강하는 뇌뿐 아니라 신장에도 손상을 유발할 수 있으며, 이러한 전신 장기 손상이 환자의 장기적인 신경학적 예후 악화와 연결될 가능성을 제시하였다. 이는 혈압조절 목표를 단순한 고정 혈압 수치가 아니라 혈압 변동성과 저혈압 노출까지 고려하는 방향으로 발전시켜야 함을 시사한다.
이번 연구는 혈전제거술 후 혈압관리 전략에 대한 새로운 병태생리학적 근거를 제시하였으며, 향후 뇌와 신장을 동시에 보호하는 보다 정밀한 혈압조절 전략 개발의 기반이 될 것으로 기대된다. 또한 최근 국제 진료지침에서 혈전제거술 후 과도한 혈압강하를 권고하지 않는 근거를 뒷받침하는 중요한 임상적 근거를 제공하였다.
이를 바탕으로 연구팀은 현재 혈압 목표를 더욱 정밀하게 규명하기 위한 후속 무작위 임상시험인 OPTIMAL-BP 2 연구를 주도하고 있으며, 국제 다기관 무작위 임상시험인 ENCHANTED 3에도 참여하고 있다. OPTIMAL-BP 2는 기존 연구와 세 가지 중요한 차별점을 가진다. 첫째, 성공적인 혈관 재개통 후 수축기혈압이 150 mmHg 미만인 환자를 대상으로 한다. 기존 연구에서는 전체 환자의 약 44%가 이에 해당하였으나, 이들 환자의 적정 혈압조절에 대한 무작위 임상시험은 아직 수행된 바 없다. 둘째, 기저 수축기혈압에 따라 목표 혈압을 개별적으로 설정하는 맞춤형 혈압조절 전략을 적용한다. 셋째, 혈압이 낮은 환자에서는 기저치 대비 혈압을 최대 20%(최대 160 mmHg)까지 상승시키는 전략을 평가하는 세계 최초 무작위 임상시험이다. ENCHANTED 3가 수축기혈압 150 mmHg 이상인 환자를 대상으로 하는 만큼, 두 연구의 결과를 종합하면 혈전제거술 후 다양한 혈압 범위의 환자에서 최적의 혈압 목표를 제시하는 중요한 근거를 마련할 것으로 기대된다.
논문: https://www.ahajournals.org/doi/10.1161/STROKEAHA.126.056127
Graphical abstract: https://www.ahajournals.org/cms/10.1161/STROKEAHA.126.056127/asset/65788651-3d12-4a8b-9b2d-9f6bdb61b583/assets/graphic/strokeaha.126.056127.abstract1.jpg
논문정보
- Research article
- 2026년 07월 (BRIC 등록일 2026-07-31)
- 국내 연구진
- 의약학 > 신경의학
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