Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia · 2025
Renal impairment and prognosis in mannitol-treated intracerebral hemorrhage: a retrospective clinical analysis.
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Yang Xiyao, Liu Zixuan, Chen Xianglan, Deng Shuixiang, Wang Zhengyang, Jin Junjie
Аннотация
BACKGROUND: Mannitol is commonly used to control intracranial hypertension in intracerebral hemorrhage (ICH), yet its renal safety and impact on clinical outcomes remain uncertain.
OBJECTIVE: To evaluate the association between mannitol exposure, acute kidney injury (AKI), and in-hospital mortality in adults with spontaneous ICH.
METHODS: We performed a retrospective cohort study using MIMIC-IV. Patients were grouped by receipt of mannitol during the ICU stay. To address confounding, we used propensity score matching (PSM) and inverse-probability-of-treatment weighting (IPTW) with balance diagnostics. Primary outcomes were AKI (KDIGO criteria) and in-hospital mortality. Prespecified subgroup analyses included baseline Glasgow Coma Scale (GCS), and time-to-event analyses used Cox models. Because direct invasive intracranial pressure (ICP) data were available in only a minority of patients (≈29%), invasive ICP trajectories were presented descriptively for this subset without imputation and were not incorporated into adjusted outcome models.
RESULTS: Of 2,421 eligible patients, 398 received mannitol. After PSM, mannitol use was associated with higher in-hospital mortality (48.7 % vs 22.0 %; p < 0.001) and AKI (38.7 % vs 22.9 %; p < 0.001). In patients with GCS ≤ 8, mortality remained higher in the mannitol group. IPTW analyses demonstrated directionally consistent associations with satisfactory post-weighting covariate balance. In the invasive-ICP subset, elevated first ICP was more common among mannitol recipients (descriptive analysis), consistent with confounding by indication.
CONCLUSIONS: In this large, real-world ICH cohort, mannitol exposure was associated with increased risks of AKI and in-hospital mortality, particularly among patients with severe neurological impairment. Given substantial missingness of invasive ICP and the observational design, residual confounding cannot be excluded. These findings support judicious, indication-driven use of mannitol with proactive renal monitoring, and underscore the need for prospective studies with standardized ICP monitoring and detailed exposure profiling.
OBJECTIVE: To evaluate the association between mannitol exposure, acute kidney injury (AKI), and in-hospital mortality in adults with spontaneous ICH.
METHODS: We performed a retrospective cohort study using MIMIC-IV. Patients were grouped by receipt of mannitol during the ICU stay. To address confounding, we used propensity score matching (PSM) and inverse-probability-of-treatment weighting (IPTW) with balance diagnostics. Primary outcomes were AKI (KDIGO criteria) and in-hospital mortality. Prespecified subgroup analyses included baseline Glasgow Coma Scale (GCS), and time-to-event analyses used Cox models. Because direct invasive intracranial pressure (ICP) data were available in only a minority of patients (≈29%), invasive ICP trajectories were presented descriptively for this subset without imputation and were not incorporated into adjusted outcome models.
RESULTS: Of 2,421 eligible patients, 398 received mannitol. After PSM, mannitol use was associated with higher in-hospital mortality (48.7 % vs 22.0 %; p < 0.001) and AKI (38.7 % vs 22.9 %; p < 0.001). In patients with GCS ≤ 8, mortality remained higher in the mannitol group. IPTW analyses demonstrated directionally consistent associations with satisfactory post-weighting covariate balance. In the invasive-ICP subset, elevated first ICP was more common among mannitol recipients (descriptive analysis), consistent with confounding by indication.
CONCLUSIONS: In this large, real-world ICH cohort, mannitol exposure was associated with increased risks of AKI and in-hospital mortality, particularly among patients with severe neurological impairment. Given substantial missingness of invasive ICP and the observational design, residual confounding cannot be excluded. These findings support judicious, indication-driven use of mannitol with proactive renal monitoring, and underscore the need for prospective studies with standardized ICP monitoring and detailed exposure profiling.