Risk stratification and prognostic outcomes in intracerebral hemorrhage among patients with chronic kidney disease: a population-oriented meta-analysis

Background Spontaneous intracerebral hemorrhage (ICH) remains one of the most devastating stroke subtypes, with early case fatality frequently exceeding 40% and a high burden of long-term disability. Chronic kidney disease (CKD) has emerged as a major systemic determinant of both ICH risk and prognosis, with observational and genetic studies indicating that reduced kidney function independently increases the likelihood of spontaneous ICH and subsequent poor functional outcome. CKD-related endothelial dysfunction, chronic inflammation, and disordered hemostasis promote vascular fragility, larger baseline hematoma volume, and higher rates of hematoma expansion, yet the prognostic impact of CKD stage on ICH survival, disability, and hematoma behavior, and its value for formal risk stratification, remains incompletely defined. Methods A comprehensive search of MEDLINE, the Embase database, WoS, the Cochrane Library's databases, and Scopus from inception through 2024 yielded 2,475 citations, of which 30 study results including people with spontaneous ICH satisfied the eligibility criteria. CKD criteria varied among studies and included lowered eGFR below 60 ml/min/1.73 m 2 , more advanced dysfunction with eGFR below 30, and ESRD needing dialysis. The major outcomes were death at 30, 90 days, and 1 year, whereas secondary outcomes included poor functional ability defined by an adjusted Rankin Scale score of 4–6 and indications of hematoma expansion. Results Across 5,000 patients, CKD was interlinked with higher 30–day (pooled OR/HR 1.89, 95% CI: 1.52–2.35), 90–day (2.14, 1.78–2.58), and 1–year mortality (2.87, 2.31–3.56) vs. non–CKD. Severe CKD and ESRD showed the greatest risk, with 1–year mortality >80% in several cohorts. Poor functional outcome was more frequent in CKD (OR/HR: 3.12, 2.45–3.98), and hematoma expansion was approximately doubled (2.01, 1.56–2.59). Heterogeneity was moderate–to–high ( I 2 : 60%−80%), partly explained by older age, higher diabetes prevalence, and greater anticoagulant use in meta–regression. GRADE rated evidence as moderate for mortality and functional dependence, and low for hematoma expansion. Conclusion CKD, particularly eGFR < 30 ml/min/1.73 m 2 and ESRD, independently and substantially worsens survival and functional recovery after ICH. Incorporating renal function into ICH prognostic scores and care pathways could improve risk stratification, guide resource allocation, and support early goals–of–care discussions. Prospective, CKD–specific ICH cohorts and interventional studies are urgently needed.