Serum prealbumin (transthyretin) predict good outcome in young patients with cerebral infarction

Serum Prealbumin as a Potential Predictive Factor for Age-Related Hearing Loss: A Retrospective Study

Objectives: Age-related hearing loss (ARHL) is a complex disease associated with the interaction of multiple factors. Furthermore, indicators of liver function represent the body's metabolic, immune, and repair abilities. This study investigated correlations between liver function and ARHL. Methods: A total of 107 patients with ARHL and 107 age- and sex-matched healthy volunteers were included. Linear correlations, logistic regression, and receiving operator characteristic curves were used to assess the associations between liver function and ARHL. Results: Serum prealbumin (PAB) levels were significantly lower in the ARHL group compared to the control group. Logistic regression analysis indicated that low PAB levels may be an independent risk factor for ARHL. The ARHL was divided into 2 groups according to the degree of hearing loss (moderately severe-to-profound and mild-to-moderate); the median ages in the 2 groups were 70.48 and 66.85 years, respectively, with the difference being significant. Age was an independent risk factor for moderately severe-to-profound ARHL, as shown by the logistic regression analysis. Conclusions: Lower PAB levels in patients with ARHL suggested that PAB may be a risk factor for ARHL. Furthermore, higher age in patients with ARHL was associated with a greater degree of hearing loss.

High fibrinogen-prealbumin ratio (FPR) predicts stroke-associated pneumonia

OBJECTIVES

Although numerous factors had been found to be associated with stroke-associated pneumonia (SAP), the underlying mechanisms of SAP remain unclear. Fibrinogen-prealbumin ratio (FPR) is a novel indicator that could balance the effects of inflammation and nutrition, which might reflect biological status of patients more comprehensively than other biomarkers. To date, FPR has not been explored in acute ischemic stroke patients. This study aims to explore the relationship between FPR and SAP.

MATERIALS AND METHODS

900 stroke patients participated in this retrospective study and 146 healthy controls were recruited. Fibrinogen and prealbumin were measured within 24 hours on admission. FPR was calculated after dividing fibrinogen (g/L) by prealbumin (mg/L) × 1000. SAP was defined according to the modified Centers for Disease Control criteria.

RESULTS

121 patients were diagnosed with SAP. Log10FPR was higher in stroke patients than healthy controls. In logistic regression analysis, log10FPR was independently associated with SAP (OR 15.568; 95% CI: 3.287-73.732; P=0.001). Moreover, after using ROC curve, the predictive power of "current standard"(defined as A2DS2 plus leukocyte count and log10hs-CRP) plus log10FPR (0.832[0.804-0.857]) was higher than "current standard" (0.811[0.782-0.837], P=0.0944) and A2DS2 plus log10FPR (0.801[0.772-0.828], P=0.0316). No significant difference was found between the predictive power of A2DS2 plus log10FPR and "current standard" (P =0.6342).

CONCLUSION

Higher FPR was observed in stroke patients compared with healthy controls and was significantly associated with SAP. FPR might provide useful clues for timely identification and treatment of SAP.

Hydroxytyrosol, a Promising Supplement in the Management of Human Stroke: An Exploratory Study

Hydroxytyrosol (HT) is a bioactive olive oil phenol with beneficial effects in a number of pathological situations. We have previously demonstrated that an HT-enriched diet could serve as a beneficial therapeutic approach to attenuate ischemic-stroke-associated damage in mice. Our exploratory pilot study examined this effect in humans. Particularly, a nutritional supplement containing 15 mg of HT/day was administered to patients 24 h after the onset of stroke, for 45 days. Biochemical and oxidative-stress-related parameters, blood pressure levels, serum proteome, and neurological and functional outcomes were evaluated at 45 and 90 days and compared to a control group. The main findings were that the daily administration of HT after stroke could: (i) favor the decrease in the percentage of glycated hemoglobin and diastolic blood pressure, (ii) control the increase in nitric oxide and exert a plausible protective effect in oxidative stress, (iii) modulate the evolution of the serum proteome and, particularly, the expression of apolipoproteins, and (iv) be beneficial for certain neurological and functional outcomes. Although a larger trial is necessary, this study suggests that HT could be a beneficial nutritional complement in the management of human stroke.

The association between prealbumin concentration at admission and mortality in elderly patients with hip fractures: a cohort study

Malnutrition is associated with complications and mortality in patients of hip fracture. Prealbumin may be more suitable than albumin to accurately predict the prognosis of hip fracture in elderly patients. We found that prealbumin concentration was nonlinearly associated with mortality in elderly patients with hip fracture, and an inflection point effect was observed.

OBJECTIVE

To evaluate the association between prealbumin concentration at admission and mortality in elderly patients with hip fractures.

METHODS

Elderly patients with hip fractures were screened between Jan 2015 and Sep 2019. Demographic and clinical characteristics of the patients were collected. Linear and nonlinear multivariate Cox regression models were used to identify the association between prealbumin concentration at admission and mortality. All analyses were performed using EmpowerStats and the R software.

RESULTS

This cohort study included 2387 patients who met the study criteria. The mean follow-up was 37.64 months. The prealbumin concentration was 162.67 ± 43.2 mg/L. Multivariate Cox regression showed that prealbumin concentration was associated with mortality in geriatric patients with hip fracture (hazard ratio [HR] = 0.95, 95% confidence intervals [CI]: 0.93-0.97, P < 0.0001). In addition, an inflection point effect was observed in the nonlinear association. The inflection point was 162.2 mg/L. If it is less than this inflection point, then every 10 mg/L increase in prealbumin was associated with a 7% reduction in the risk of death (HR = 0.93, 95%CI: 0.90-0.96, P < 0.0001). When greater than the inflection point, there was no difference in the risk of death (HR = 0.99, 95%CI: 0.95-1.03, P = 0.5127).

CONCLUSION

The prealbumin concentrations at admission were nonlinearly associated with long-term mortality in geriatric hip fractures, and 162.2 mg/L could be considered a prognostic factor of mortality risk.

Altered levels of transthyretin in human cerebral microdialysate after subarachnoid haemorrhage using proteomics; a descriptive pilot study

BACKGROUND

Subarachnoid haemorrhage (SAH) is one of the most severe forms of stroke in which delayed cerebral ischemia is one of the major complications. Neurointensive care aims at preventing and treating such complications and identification of biomarkers of early signs of ischemia might therefore be helpful.

METHODS

We aimed at describing proteome profile in cerebral microdialysate in four patients with aneurysmal SAH using two dimensional gel electrophoresis in combination with mass spectrometry in search for new biomarkers for delayed cerebral ischemia and to investigate if there were temporal fluctuations in those biomarkers over time after aneurysmal bleed.

RESULTS

The results showed transthyretin in nine different proteoforms (1001, 1102, 2101, 3101, 4101, 4102, 5001, 5101, 6101) in cerebral microdialysate samples from four patients having sustained SAH. Several proteoforms show highly differing levels and pooled analysis of all samples showed varying optical density related to time from aneurysmal bleed, indicating a temporal evolution.

CONCLUSIONS

Transthyretin proteoforms have not earlier been shown in cerebral microdialysate after SAH and we describe differing levels based on proteoform as well as time from subarachnoid bleed. Transthyretin is well known to be synthetized in choroid plexus, whilst intraparenchymal synthesis remains controversial. The results need to be confirmed in larger studies in order to further describe transthyretin.

Patisiran for the Treatment of Transthyretin-mediated Amyloidosis with Cardiomyopathy

Transthyretin (TTR) is a tetrameric protein, synthesized primarily by the liver, that acts as a physiological transport protein for retinol and thyroxine. TTR can misfold into pathogenic amyloid fibrils that deposit in the heart and nerves, causing a life-threatening transthyretin amyloidosis cardiomyopathy (ATTR-CM), and a progressive and debilitating polyneuropathy (ATTR-PN). Recent therapeutic advances have resulted in the development of drugs that reduce TTR production. Patisiran is a small interfering RNA that disrupts the complimentary mRNA and inhibits TTR synthesis, and is the first gene-silencing medication licensed for the treatment of ATTR amyloidosis. After encouraging results following the use of patisiran for the treatment of patients with ATTR-PN, there has been increasing interest in the use of patisiran for the treatment of ATTR-CM. Various studies have demonstrated improvements across a wide range of cardiac biomarkers following treatment with patisiran, and have changed the perception of ATTR-CM from being thought of as a terminal disease process, to now being regarded as a treatable disease. These successes represent a huge milestone and have the potential to revolutionize the landscape of treatment for ATTR-CM. However, the long-term safety of patisiran and how best to monitor cardiac response to treatment remain to be determined.

RNA Targeting and Gene Editing Strategies for Transthyretin Amyloidosis

Transthyretin (TTR) is a tetrameric protein synthesized primarily by the liver. TTR can misfold into pathogenic ATTR amyloid fibrils that deposit in the nerves and heart, causing a progressive and debilitating polyneuropathy (PN) and life-threatening cardiomyopathy (CM). Therapeutic strategies, which are aimed at reducing ongoing ATTR amyloid fibrillogenesis, include stabilization of the circulating TTR tetramer or reduction of TTR synthesis. Small interfering RNA (siRNA) or antisense oligonucleotide (ASO) drugs are highly effective at disrupting the complementary mRNA and inhibiting TTR synthesis. Since their development, patisiran (siRNA), vutrisiran (siRNA) and inotersen (ASO) have all been licensed for treatment of ATTR-PN, and early data suggest these drugs may have efficacy in treating ATTR-CM. An ongoing phase 3 clinical trial will evaluate the efficacy of eplontersen (ASO) in the treatment of both ATTR-PN and ATTR-CM, and a recent phase 1 trial demonstrated the safety of novel in vivo CRISPR-Cas9 gene-editing therapy in patients with ATTR amyloidosis. Recent results from trials of gene silencer and gene-editing therapies suggest these novel therapeutic agents have the potential to substantially alter the landscape of treatment for ATTR amyloidosis. Their success has already changed the perception of ATTR amyloidosis from a universally progressive and fatal disease to one that is treatable through availability of highly specific and effective disease-modifying therapies. However, important questions remain including long-term safety of these drugs, potential for off-target gene editing, and how best to monitor the cardiac response to treatment.Kindly check and confirm the processed running title.This is correct.

Prealbumin as a nutrition status indicator may be associated with outcomes of geriatric hip fractures: a propensity score matching and 1-year follow-up study

AIM

Nutrition status may affect bone metabolism and regeneration in the elderly. However, few studies reported a sensitive nutrition indicator or evaluation tool for geriatric hip fractures. This study aimed to explore if prealbumin (PAB), a critical nutrition-related protein, is related to the prognosis of hip fractures.

METHODS

Patients with hip fractures who met the inclusion criteria were included in our study. Geriatric nutritional risk index (GNRI) and prognostic nutritional index (PNI) were calculated. Propensity score matching (PSM) was used to reduce the influence of confounding factors and ROC curves were conducted to explore the optimal cutoff points of PAB and to compare the prognostic value between GNRI, PNI, and PAB. Then Cox and Logistics analyses were performed to identify the relation between PAB and outcomes of hip fractures.

RESULTS

Out of the 546 patients enrolled in this study, 91 patients died within one year. After a 1:1 PSM, the patients with less than 1-year survival had significantly lower PAB (p < 0.001) than those who were still alive at one year. ROC curves showed that the PAB may sensitively predict 6-month survival (AUROC: 0.695), 1-year survival (AUROC: 0.696), and 1-year-free walking ability (AUROC: 0.642). Logistics analysis showed that low PAB may be an independent risk factor for survival and 1-year-free walking ability.

CONCLUSION

Low levels of PAB may be associated with poor survival and walking abilities of older patients after surgery for hip fracture.

Association between serum transthyretin and intracranial atherosclerosis in patients with acute ischemic stroke

Background

Intracranial atherosclerotic stenosis (ICAS) is a primary cause of ischemic stroke. In addition to dyslipidemia, inflammation has been recognized as a potential pathogenesis of atherosclerosis. It remains unknown whether there is a link between transthyretin and ICAS as an inflammatory index.

Methods

Consecutive patients with acute ischemic stroke admitted to the Second Affiliated Hospital of Wenzhou Medical University between January 2019 and June 2020 were retrospectively analyzed. Blood samples were collected from all patients within 24 h of admission to detect their serum transthyretin levels. ICAS was defined as at least one intracranial artery stenosis on vascular examination with a degree of stenosis ≥50%. Multivariable logistic regression analysis was used to identify independent factors associated with ICAS. Restricted cubic spline models were used to depict patterns in the association between serum transthyretin levels and ICAS.

Results

In total, 637 patients with acute ischemic stroke were included in this study, of whom 267 (41.9%) had ICAS. Compared with the patients without ICAS, serum transthyretin levels in patients with ICAS were significantly lower (226.3 ± 56.5 vs. 251.0 ± 54.9 mg/L; p < 0.001). After adjusting for potential confounders, patients in the lowest tertile showed a significant increase in ICAS compared to those in the highest tertile (odds ratio, 1.85; 95% confidence interval, 1.12–3.05; p = 0.016). This negative linear association is also observed in the restricted cubic spline model. However, this association may only be observed in men. Age, National Institutes of Health Stroke Scale score, hemoglobin A1c level, and low-density lipoprotein cholesterol level were independently associated with ICAS.

Conclusions

Decreased serum transthyretin levels are associated with a more severe ICAS burden in patients with acute ischemic stroke. Our findings suggest that transthyretin may play a role in the pathogenesis of ICAS and provide insight into the control of inflammation for the treatment of ICAS.

Low serum transthyretin levels predict stroke-associated pneumonia

BACKGROUND AND AIMS

Stroke-associated pneumonia (SAP) is commonly seen in ischemic stroke patients. Low transthyretin levels are found to be correlated with stroke. This study aims to investigate the potential relationship between transthyretin levels and SAP.

METHODS AND RESULTS

In total, 920 patients were involved in our study. Serum transthyretin levels were measured within 24 h at admission. We defined SAP according to the modified Centers for Disease Control criteria. In the study population, 123 (13.4%, 77 men, 46 women) were diagnosed with SAP. In the multivariable analysis, we found that serum transthyretin levels were significantly lower in SAP compared with non-SAP patients (231 ± 80 vs. 279 ± 75; P < 0.001) after adjusting for confounders. Meanwhile, we discovered that low transthyretin levels (≤252 mg/L) were independently associated with the development of SAP (OR 3.370; 95% CI: 1.763-6.441; P < 0.001). Moreover, patients with SAP had a worse clinical outcome than those without SAP at discharge. In addition, dysphagia, leukocyte count and NLR (neutrophil-to-lymphocyte ratio) were also found to be associated with SAP.

CONCLUSION

We found that low transthyretin levels significantly increased the risk of SAP. Patients with high risk of developing SAP could be early identified and prevented timely.

Effect of Preoperative Serum Transthyretin Levels on Postoperative Clinical Results and Morbidity in Patients Undergoing Spinal Surgery

Introduction This study aims to investigate the effects of preoperative serum transthyretin (TTR) levels on surgical success, pain scores, and postoperative morbidity.

Methods Note that, in our clinic, 188 patients who were operated for spinal pathologies between June 2010 and January 2011 were included in this study. Blood samples were drawn from all patients on the morning of surgery and then serum TTR measurements were made. Demographic data of all patients were collected, and then their preoperative and postoperative neurological examinations, Karnofsky scores, visual analog scale (VAS) scores, Oswestry Disability Index (ODI) scores, postoperative infection and wound healing status, hospital stay, and morbidity levels were recorded and TTR levels were compared.

Results When preoperative TTR level of patients were low, their Karnofsky scores decreased, ODI scores increased, the early postoperative VAS and late postoperative VAS values increased, and the length of hospital stay was increased. Moreover, in patients with low TTR levels, postoperative Karnofsky scores were lower, postoperative ODI levels were higher, postoperative early and late VAS scores were higher, hospital stays were longer, peroperative complication rates were higher, wound infection rates were higher, the delay in wound site healing was higher, and the morbidity rate was higher.

Conclusion Consequently, preoperative low TTR levels have been reported to be an effective parameter that can be used to predict surgical results, wound infection and wound site healing status, perioperative complications, and morbidity in spinal surgery.

Are we creating a new phenotype? Physiological barriers and ethical considerations in the treatment of hereditary transthyretin-amyloidosis

Hereditary transthyretin (TTR) amyloidosis (ATTRv) is an autosomal dominant, systemic disease transmitted by amyloidogenic mutations in the TTR gene. To prevent the otherwise fatal disease course, TTR stabilizers and mRNA silencing antisense drugs are currently approved treatment options. With 90% of the amyloidogenic protein produced by the liver, disease progression including polyneuropathy and cardiomyopathy, the two most prominent manifestations, can successfully be halted by hepatic drug targeting or-formerly-liver transplantation. Certain TTR variants, however, favor disease manifestations in the central nervous system (CNS) or eyes, which is mostly associated with TTR production in the choroid plexus and retina. These compartments cannot be sufficiently reached by any of the approved medications. From liver-transplanted patients, we have learned that with longer lifespans, such CNS manifestations become more relevant over time, even if the underlying TTR mutation is not primarily associated with such. Are we therefore creating a new phenotype? Prolonging life will most likely lead to a shift in the phenotypic spectrum, enabling manifestations like blindness, dementia, and cerebral hemorrhage to come out of the disease background. To overcome the first therapeutic limitation, the blood-brain barrier, we might be able to learn from other antisense drugs currently being used in research or even being approved for primary neurodegenerative CNS diseases like spinal muscular atrophy or Alzheimer's disease. But what effects will unselective CNS TTR knock-down have considering its role in neuroprotection? A potential approach to overcome this second limitiation might be allele-specific targeting, which is, however, still far from clinical trials. Ethical standpoints underline the need for seamless data collection to enable more evidence-based decisions and for thoughtful consenting in research and clinical practice. We conclude that the current advances in treating ATTRv amyloidosis have become a meaningful example for mechanism-based treatment. With its great success in improving patient life spans, we will still have to face new challenges including shifts in the phenotype spectrum and the ongoing need for improved treatment precision. Further investigation is needed to address these closed barriers and open questions.

Comparison of Liver Biomarkers in 288 COVID-19 Patients: A Mono-Centric Study in the Early Phase of Pandemic

Background and Aims: Recent reports have indicated that hepatic dysfunction occurred in a proportion of patients with coronavirus disease 2019 (COVID-19). We aimed to compare and describe the liver biomarkers in different subtypes of COVID-19 patients. Methods: This study enrolled 288 COVID-19 patients in Huangshi Hospital of Traditional Chinese Medicine. All patients were divided into ordinary, severe, and critical groups according to the Diagnosis and Treatment Protocol for Novel Coronavirus Pneumonia (Trial Version 7). Demographic, clinical characteristics and liver biomarkers were compared among the three groups. Results: During hospitalization, AST, TBiL, and ALP levels in ordinary and severe patients fluctuated within the normal range with a rising trend in critical patients except AST. ALT and GGT levels fluctuated within the normal range showing an upward trend, while LDH levels in the critical group exceeded the normal range. Prealbumin showed an upward trend, especially in the severe group. At discharge, AST and LDH levels in ordinary and severe groups were lower than their baselines but increased in the critical group. In contrast to albumin, TBiL levels were increased in ordinary and critical groups while decreased in the severe group. The stratified analysis revealed factors affecting liver function in critical cases included highest temperature ≥38.0°C, age ≥60 and symptom of hypoxemia. Conclusions: COVID-19 can cause severe hepatic dysfunction in critical patients, requiring early monitoring and intervention. LDH, ALP, GGT, TBiL, prealbumin, and albumin may be helpful for evaluating and predicting disease prognosis due to their correlation with disease severity in COVID-19.

A Narrative Review of the Role of Transthyretin in Health and Disease

Transthyretin (TTR) is a tetrameric transport protein highly conserved through vertebrate evolution and synthesized in the liver, choroid plexus, and retinal pigment epithelium. TTR transports the thyroid hormone thyroxine and the retinol-binding protein (RBP) bound to retinol (vitamin A). Mutations in TTR are associated with inherited transthyretin amyloidosis (ATTRv), a progressive, debilitating disease that is ultimately fatal and is characterized by misfolding of TTR and aggregation as amyloid fibrils, predominantly leading to cardiomyopathy or polyneuropathy depending on the particular TTR mutation. Transthyretin amyloid cardiomyopathy can also occur as an age-related disease caused by misfolding of wild-type TTR. Apart from its transport role, little is known about possible additional physiological functions of TTR. Evidence from animal model systems in which TTR has been disrupted via gene knockout is adding to our cumulative understanding of TTR function. There is growing evidence that TTR may have a role in neuroprotection and promotion of neurite outgrowth in response to injury. Here, we review the literature describing potential roles of TTR in neurobiology and in the pathophysiology of diseases other than ATTR amyloidosis. A greater understanding of these processes may also contribute to further clarification of the pathology of ATTR and the effects of potential therapies for TTR-related conditions.

Quick and effective improvement of leucine enriched dietary supplement on malnutrition in acute stroke patients receiving enteral tube feeding

Background

Malnutrition often occurs in acute stroke patients receiving enteral tube feeding (ETF). Unless malnutrition is improved, their clinical outcome is poor. However, strategies to improve malnutrition in these patients have not been established. Branched-chain amino acids (BCAA) may enhance protein synthesis and attenuate inflammation. Our study aimed to investigate whether a leucine enriched BCAA dietary supplement (LEBDs) could quickly increase serum levels of albumin (Alb) or transthyretin (TTR) and decrease high-sensitivity C-reactive protein (CRP) in the development of severe malnutrition within a few days after stroke onset compared to standard BCAA dietary supplement (SBDs).

Methods

We retrospectively included acute stroke patients who: 1) were admitted between August 2016 and July 2017; 2) underwent ETF for 7 days or longer after admission, and 3) underwent blood examination of Alb, TTR, and CRP on admission, the fifth day and the seventh day. We defined severe malnutrition as severe hypoproteinemia: decrease of TTR to less than 15 mg/dl on the 5th day. In LEBDs and SBDs groups, patients started to receive a dietary supplement containing leucine of 1.44 and 0. 72 g twice a day on the fifth day, respectively. We evaluated Alb (g/dl), TTR (mg/dl), and CRP (mg/dl) on admission, the fifth day, and the seventh day.

Results

Twenty-nine patients met our inclusion criteria:15 in LEBDs and 14 in SBDs. In LEBDs and SBDs groups, the median Alb was 3.5 and 3.3 g/dl, TTR was 12.7 and 10.7 mg/dl, and CRP was 1.02 and 0.673 mg/dl on admission, respectively. In LEBDs, the median Alb and TTR decreased to 2.6 g/dl and 11.9 mg/dl, and CRP increased to 5.337 mg/dl on the fifth day. On the 7th day, TTR increased, and CRP decreased, although Alb did not improve. In SBDs, the median Alb and TTR decreased to 2.6 g/dl and 9.7 mg/dl, and CRP increased to 4.077 mg/dl on the fifth day. On the 7th day, Alb, TTR, and CRP did not improve.

Conclusion

In acute stroke patients receiving leucine enriched BCAA dietary supplement, quick improvements in transthyretin and CRP were observed.

Prealbumin: The clinical utility and analytical methodologies

Prealbumin is a small protein which has been widely evaluated as a nutritional and a prognostic marker. The small size and concentration of prealbumin in blood proposes challenges on measuring it with high sensitivity and specificity. Over the years, a number of analytical methodologies have been developed, which may help establish prealbumin as a useful biomarker in routine clinical practice. The aim of the short review was to explore the current literature on the clinical utility of prealbumin and the advances made in the analytical methodologies of prealbumin. We searched MEDLINE, EMBASE and the Cochrane Library for articles published between January 1980 and July 2019, with the general search terms of 'prealbumin', 'prognostic marker', 'nutritional marker', 'analytical methodologies' and 'malnutrition'. Additionally, we selected relevant articles and comprehensive overviews from reference lists of identified studies. The routine use of prealbumin in clinical practice remains debatable; however; it can complement clinical history, anthropometric assessment and physical examination to assess malnutrition with more certainty. Consensus on the clinical applications of prealbumin in the management of malnutrition is warranted.

Association of prealbumin levels with contrast-induced acute kidney injury in elderly patients with elective percutaneous coronary intervention

Purpose

Inflammatory factors play a critical role in contrast-induced acute kidney injury (CI-AKI). Prealbumin, a nutritional and inflammatory indicator, is a well-established predictor of short- and long-term outcomes in numerous clinical conditions. The current study investigated the association of pre-procedural prealbumin levels with CI-AKI and long-term outcomes in geriatric patients after elective percutaneous coronary intervention (PCI).

Patients and methods

A total of 558 patients aged≥75 years, who underwent elective PCI between January 2012 and December 2015, were selected for the current study. Pre-procedural prealbumin levels were measured before PCI. Multivariable logistic regression and Cox proportional hazard regression analyses were performed to identify the independent risk factors for CI-AKI and long-term mortality.

Results

Out of 558 patients, 54 developed CI-AKI. The optimal cutoff value of prealbumin for detecting CI-AKI was 185.5 mg/L with 62.7% sensitivity and 70.4% specificity based on the receiver operating characteristic analysis (C-statistic=0.710; 95% confidence interval [CI] 0.673–0.751). Multivariable analysis demonstrated that prealbumin≤185.5 mg/L was significantly associated with CI-AKI (odds ratio [OR] 0.397; 95% CI 0.195–0.808; P=0.011). Cox regression analysis demonstrated that prealbumin≤185.5 mg/L was associated with long-term mortality (adjusted hazard ratio [HR] 0.525; 95% CI 0.289–0.952; P=0.034) during the follow-up.

Conclusion

Pre-procedural levels of prealbumin were independently associated with an increased risk of CI-AKI and long-term mortality in elderly patients undergoing elective PCI.

Predictive value of serum transthyretin for outcome in acute ischemic stroke

Introduction

The impact of choroid plexus with its blood–cerebrospinal fluid barrier in the ischemic stroke pathology is poorly explored. Transthyretin (TTR) is a protein synthesized in liver and just in choroid plexus.

Objectives

The current study was designed to assess the prognostic value of serum TTR for functional outcome (at the time of hospital discharge) and long-term (one-year) overall mortality in ischemic stroke patients.

Patients and methods

We conducted a prospective observational study. Patients (n = 81) with acute (< 24 hours of symptoms onset) ischemic stroke consecutively admitted to Stroke Unit were included. An unfavorable outcome was defined as a modified Rankin Scale (mRS) score ≥ 3. The relationships between serum TTR levels and clinical outcome were analyzed using multivariate analysis. One-year mortality was analyzed by Kaplan–Meier survival curves stratified by mean value of TTR.

Results

Compared with patients with mRS <3, patients with an unfavorable outcome at hospital discharge had significantly lower TTR levels on admission (P < 0.0001). In non-survivals serum TTR levels were significantly lower compared with patients who survive one year of observation (P = 0.009). Using multivariate analysis, transthyretin emerged as an independent predictor for unfavorable outcome at the day of hospital discharge (adjusted odds ratio = 0.96; 95% CI: 0.9–0.99, P <0.05). A one-year mortality of patients with the lower TTR levels was significantly higher than in patients with TTR levels above mean value (P = 0.02).

Conclusions

Serum level of TTR at admission was a predictor of functional outcome after ischemic stroke and was also associated with one-year mortality in stroke survivals.

Low serum prealbumin levels in post-stroke depression

Previous studies have shown that prealbumin is associated with depression. However, the association between prealbumin and post-stroke depression remains unelucidated. This observational cohort study determined whether low baseline serum prealbumin could predict post-stroke depression at 1 month in patients admitted with acute stroke. The study, conducted from October 2013 to September 2014, included 307 patients with acute stroke who were followed-up for 1 month. Serum prealbumin was measured within 24h after admission using an immunoturbidimetric method. The17-item Hamilton Depression Scale was used to evaluate depression symptoms. Patients with a depression score of ≥7 were evaluated using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th edition, for diagnosing post-stroke depression at 1 month. Binary logistic regression analysis was used to evaluate possible predictors of post-stroke depression. Overall, 93 (30.3%) patients were diagnosed with post-stroke depression. Serum prealbumin was significantly lower in patients with versus those without post-stroke depression, and was a significant predictor of post-stroke depression after adjusting for confounding risk factors. In conclusion, baseline serum prealbumin level was associated with post-stroke depression at 1 month, suggesting that prealbumin might be a useful biomarker for post-stroke depression.

Serum prealbumin is a predictive biomarker for stroke-associated infection after an ischemic stroke

BACKGROUND

Several prior studies have linked serum prealbumin (PA) as a predictor for perioperative infection. However, whether peripheral blood PA levels can be used as an indicator of stroke-associated infection (SAI) is still unclear. In this study, we attempt to find whether serum PA is a meaningful predictor in SAI after an ischemic stroke, so as to provide theoretical basis for clinical treatment.

METHODS

Consecutive patients with acute ischemic stroke who were admitted to our hospital were enrolled and serum PA was collected. A prospective study was conducted to observe the predictive value of PA in the SAI incident in ischemic stroke patients.

RESULTS

Of 104 patients, 29 (27.9%) developed an SAI after 7 d of follow-up. The stroke with SAI group had significantly lower PA levels than the stroke without SAI group (  p < 0.05). The optimal cutoff value for predicting SAI was PA ≤ 191 mg/L, with sensitivity and specificity of 58.62% and 81.33%, respectively. Kaplan-Meier survival analysis showed that stroke patients with low serum PA level (PA ≤ 191 mg/L) had a higher SAI rates (log-rank test, χ² = 16.870, p < 0.001). Cox regression analysis showed that PA ≤ 191 mg/L (hazard ratio = 3.207; 95% CI, 1.430-7.190, p = 0.005) was an independent risk factor for SAI.

CONCLUSIONS

Early detection of serum PA during the acute phase of ischemic stroke may help us to identify at-risk SAI patients, and hence rapidly guide the intervention to prevent SAI.

Transthyretin provides trophic support via megalin by promoting neurite outgrowth and neuroprotection in cerebral ischemia

Transthyretin (TTR) is a protein whose function has been associated to binding and distribution of thyroid hormones in the body and brain. However, little is known regarding the downstream signaling pathways triggered by wild-type TTR in the CNS either in neuroprotection of cerebral ischemia or in physiological conditions. In this study, we investigated how TTR affects hippocampal neurons in physiologic/pathologic conditions. Recombinant TTR significantly boosted neurite outgrowth in mice hippocampal neurons, both in number and length, independently of its ligands. This TTR neuritogenic activity is mediated by the megalin receptor and is lost in megalin-deficient neurons. We also found that TTR activates the mitogen-activated protein kinase (MAPK) pathways (ERK1/2) and Akt through Src, leading to the phosphorylation of transcription factor CREB. In addition, TTR promoted a transient rise in intracellular calcium through NMDA receptors, in a Src/megalin-dependent manner. Moreover, under excitotoxic conditions, TTR stimulation rescued cell death and neurite loss in TTR KO hippocampal neurons, which are more sensitive to excitotoxic degeneration than WT neurons, in a megalin-dependent manner. CREB was also activated by TTR under excitotoxic conditions, contributing to changes in the balance between Bcl2 protein family members, toward anti-apoptotic proteins (Bcl2/BclXL versus Bax). Finally, we clarify that TTR KO mice subjected to pMCAO have larger infarcts than WT mice, because of TTR and megalin neuronal downregulation. Our results indicate that TTR might be regarded as a neurotrophic factor, because it stimulates neurite outgrowth under physiological conditions, and promotes neuroprotection in ischemic conditions.

The Prognostic Value of High-sensitivity C-reactive Protein and Prealbumin for Short-term Mortality in Acutely Hospitalized Multimorbid Elderly Patients: A Prospective Cohort Study

OBJECTIVES

To establish the predictive value on mortality after 2 months from hospital admission of two laboratory markers of nutritional and inflammatory status, high-sensitivity C-reactive protein (hs-CRP) and prealbumin, in a cohort of frail multimorbid elderly without terminal illness.

DESIGN

Prospective cohort study.

SETTING

Internal medicine ward of a large teaching hospital in Italy.

PARTICIPANTS

544 Caucasian patients with acute disease consecutively admitted from January to June 2013. 102 were excluded for being younger than 65 years old, having life expectancy <30 days or not having frailty syndrome. Further 42 patients were excluded for missing data or withdrawn at follow-up. Final analysis was performed on 400 subjects (179 M, 221 F, mean age 79±10).

MEASUREMENTS

Serum prealbumin and hs-CRP were measured at admission. Death within 2 months from hospital admission was assessed through a telephonic interview with the caregiver for each patient discharged alive. Inhospital mortality was also recorded. Survival was calculated from date of admission to our unit.

RESULTS

Mean prealbumin at admission was 17.3±7.7 mg/dl, while hs-CRP median was 24.2 mg/L (IQR 8.7 to 51.8). 108 patients (27%) died within two months from admission. In an age- and sex-adjusted analysis, log(hs-CRP) levels at admission, but not prealbumin, were independently associated with an increased risk for mortality (HR 1.40, 95% CI 1.18 to 1.66, p<0.001). After multiple adjustments for covariates, including comorbidity burden measured through Charlson score, log(hs-CRP) remained significantly associated with mortality (HR 1.38, 95% CI 1.08 to 1.76, p=0.01). A Receiver Operating Characteristic (ROC) curve was performed to test the predictive value of hs-CRP at admission on two-month mortality (AUC 0.68, 95% CI 0.63 to 0.72, p<0.001). Cut-off value was set at 38.4 mg/L. After dichotomization of hs-CRP values according to this cut-off, hs-CRP≥38.4 mg/L at admission proved to be a significant risk factor for mortality (HR 2.10, 95% CI 1.23 to 3.58, p=0.006).

CONCLUSION

Serum hs-CRP, but not prealbumin, values at admission are predictors of short-term mortality at hospital admission in elderly multimorbid patients. Inflammation seems to affect prognosis more than malnutrition in this setting and may therefore guide clinicians' attitude towards therapeutic choices.

Albumin and depression in elderly stroke survivors: An observational cohort study

BACKGROUND/OBJECTIVES

Post-stroke depression affects approximately one third of stroke survivors. In non-stroke affected populations, depressive symptomatology is associated with hypoalbuminemia. This is also common among stroke survivors and associated with poor outcome and increased mortality. The role of stroke-associated hypoalbuminemia in post-stroke depression is not clear. We aimed to explore the relationship between serum albumin and post-stroke depression, as measured 20 months post-stroke.

SUBJECTS/METHODS

Observational cohort study of elderly Swedish patients drawn from the 'Gothenburg 70+ Stroke Study' (n=149) and assessed at 20 months after stroke onset. Serum albumin was drawn from venous blood and analysed with gas chromatography/mass spectrometry. Depressive symptomatology was assessed using the Montgomery-Åsberg Depression Rating Scale (MADRS) and functional impairment was assessed using the Barthel Index.

RESULTS

Analysis of covariance analysis showed that serum albumin levels were associated with depressive symptoms at 20 months after stroke. Multivariate analysis of covariance showed that disability scores at 3 days were associated with depressive symptoms at 20 months after stroke and after accounting for the age covariate. Stroke survivors were not clinically deficient in serum albumin.

CONCLUSIONS

Low serum albumin appears to be associated with depressive symptoms in elderly individuals long term post-stroke.

Plasma Transthyretin as a Biomarker of Lean Body Mass and Catabolic States

Plasma transthyretin (TTR) is a plasma protein secreted by the liver that circulates bound to retinol-binding protein 4 (RBP4) and its retinol ligand. TTR is the sole plasma protein that reveals from birth to old age evolutionary patterns that are closely superimposable to those of lean body mass (LBM) and thus works as the best surrogate analyte of LBM. Any alteration in energy-to-protein balance impairs the accretion of LBM reserves and causes early depression of TTR production. In acute inflammatory states, cytokines induce urinary leakage of nitrogenous catabolites, deplete LBM stores, and cause an abrupt decrease in TTR and RBP4 concentrations. As a result, thyroxine and retinol ligands are released in free form, creating a second frontline that strengthens that primarily initiated by cytokines. Malnutrition and inflammation thus keep in check TTR and RBP4 secretion by using distinct and unrelated physiologic pathways, but they operate in concert to downregulate LBM stores. The biomarker complex integrates these opposite mechanisms at any time and thereby constitutes an ideally suited tool to determine residual LBM resources still available for metabolic responses, hence predicting outcomes of the most interwoven disease conditions.

Serum Uric Acid Levels and Outcomes After Acute Ischemic Stroke

Previous studies assessing the association between serum uric acid levels and neurological outcome after acute ischemic stroke reported conflicting results. A systematic review and meta-analysis were conducted to assess the impact of serum uric acid levels on outcome after acute ischemic stroke. Pubmed, Embase, Web of Science, and Google scholar were searched through September 26, 2014 to identify eligible published or unpublished studies on the association between serum uric acid levels and outcome after acute ischemic stroke. Hazard ratio (HR) for poor outcome or mean differences of serum uric acid levels with 95% confidence intervals (95% CIs) were pooled using meta-analysis. The primary outcome was occurrence of poor outcomes, while the secondary outcome was the mean differences of serum uric acid levels in patients with good or poor outcomes. Ten eligible studies with a total of 8131 acute ischemic stroke patients were included into the meta-analysis. Compared with low serum uric acid level, high serum uric acid level was associated better outcome after acute ischemic stroke (HR = 0.77, 95% CI 0.68-0.88, P = 0.0001). Sensitivity analysis further identified the prognostic role of serum uric acid levels on outcome after acute ischemic stroke. Patients with good outcomes had a higher serum uric acid level compared with those with poor outcome (mean difference = 30.61 μmol/L, 95% CI 20.13-41.08, P < 0.00001). There was no obvious risk of publication bias in the meta-analysis. This meta-analysis supports that serum uric acid level has a protective effect on neurological outcome after acute ischemic stroke. High uric acid level at the onset is a biomarker of better prognosis in patients with acute ischemic stroke.

Serum albumin and prealbumin predict the poor outcome of traumatic brain injury

Background

Serum albumin and prealbumin are both negative acute-phase reactants, and usually at low levels in stress. We aim to determine their predictive values for poor outcome of traumatic brain injury (TBI).

Methods

A total of 326 patients of TBI were enrolled and followed-up by telephone 6 months after discharge. They were divided into a favorable group (GOS: 3 to 5) and an unfavorable group (GOS: 1 to 2). Serum albumin and prealbumin were measured from vein blood within 24 h after admission.

Results

Ninety one (27.9%) patients were with poor outcome (GOS: 1 to 2). The unfavorable group had lower albumin and prealbumin (P<0.001). Albumin and prealbumin were both positively correlated with GCS (r = 0.489, P<0.001; r = 0.222, P<0.001, respectively) and GOS (r = 0.518, P<0.001; r = 0.314, P<0.001, respectively). After adjustment for confounding factors, the odds ratios of albumin and prealbumin were 0.866, 95% CI: 0.829 to 0.904 and 0.990, 95% CI: 0.985 to 0.995, respectively. In subgroup of GCS≤8 (n = 101), the crude and adjusted odds ratios of serum albumin were both statistically significant (P = 0.027, P = 0.033, respectively), while prealbumin were not (P = 0.553, P = 0.576, respectively). The AUC of albumin for predicting poor outcome was 0.762, 95% CI: 0.712 to 0.807, which was significantly higher than that of prealbumin (0.664, 95% CI: 0.610 to 0.715). In analyses of all patients and subgroup of GCS≤8, the AUCs of serum albumin were both significantly higher than those of prealbumin (P = 0.001, P = 0.045, respectively).

Conclusions

Both serum albumin and prealbumin could predict the poor outcome of TBI, but the former is much better, especially, in patients with severe TBI.

Randomized trial to evaluate nutritional status and absorption of enteral feeding after brain death

CONTEXT

Catecholamines and inflammatory mediators, with elevated levels after brain death, are associated with reduced function and survival of transplanted organs. Enteral nutrition reduces tissue damage and may benefit organs.

OBJECTIVE

To evaluate the effects of immunomodulating enteral nutrition in organ donors.

DESIGN

Prospective, randomized, open-label study.

SETTING

Intensive care unit.

PATIENTS

Thirty-six brain-dead organ donors.

INTERVENTIONS

Donors were randomized to receive enteral nutrition containing omega-3 polyunsaturated fatty acid, antioxidants, and glutamine or standard care (fasting). Donors received hormonal replacement therapy of corticosteroid, levothyroxine, dextrose, and insulin.

MAIN OUTCOME MEASURES

Gastrointestinal assimilation (measured by 13 carbon-labeled uracil breath analysis), quantity of organs recovered, resting energy expenditure, urine level of urea nitrogen, and serum levels of albumin, prealbumin, interleukin 6, tumor necrosis factor-α, and C-reactive protein were evaluated.

RESULTS

Thirteen patients (36%) assimilated 13C-labeled uracil. Resting energy expenditure was significantly higher than predicted between 10 and 14 hours after baseline in 33 donors (P= .007). Other measures were not conclusively different between fed and fasting groups. No adverse events occurred that were related to the enteral feeding.

CONCLUSIONS

About 30% of donors metabolized 13C-labeled uracil, although no difference in oxidation rate was found between fasting and fed donors. Corticosteroid administration lowers plasma levels of interleukin 6 and most likely contributes to greater than predicted resting energy expenditure. Thus energy needs may not be met during fasting if hormones are given. Consequences of this possible energy deficit warrant further study.

The value of serum prealbumin in the diagnosis and therapeutic response of tuberculosis: a retrospective study

Objective

The aim of this study was to examine serum prealbumin (PA) levels in patients with tuberculosis and lung cancer, and to evaluate the correlations of serum PA levels with clinicopathological characteristics.

Method

Total 760 patients were included in the study: 320 patients with tuberculosis, 320 patients with lung cancer, and 120 healthy subjects. Serum PA was detected using a biochemical analyzer to determine the value of serum PA in the diagnosis and therapeutic response of tuberculosis.

Results

Compared to lung cancer and healthy individuals, TB patients were more frequent in suffering from low serum PA (75.0% vs.30.9% vs.6.7%,P<0.01), and the serum PA levels of TB patients were significantly reduced (137.5±42.4 mg/L vs. 183.5±49.1 mg/L vs. 240.0±43.9 mg/L, P<0.01). Among various clinical characteristics, type (with pleuritis), age (≥60), ESR (>20 mm/h) and smoking status (≥20 pack×years) were associated with low serum PA levels of TB patients, while ECOG performance status (≥2) was associated with low serum PA levels of lung cancer patients. The change of serum PA levels was in accordance with the therapeutic effects of anti-TB drugs, which might present a valuable and objective indicator for monitoring the therapeutic effects of TB drugs on TB patients.

Conclusion

Low serum prealbumin levels are very common in TB patients and can be served as a potential indicator for differential diagnosis of lung cancer and monitoring the therapeutic effects of TB drugs.

New advances in the use of serum prealbumin as an index of liver function

Serum prealbumin, mainly synthesized in the liver, can be used to assess the function of liver protein synthesis, reserve and nutritional status with many advantages such as convenience, accuracy and fewer interference factors; however, it is clinically used often as an independent factor, and there is little systematic, relevant and prospective research on it. Although serum prealbumin test has been used for a long time, many clinicians do not attach great importance to the characteristics of changes in serum prealbumin. In this paper, we will review new characteristics of biochemistry structure and function of serum prealbumin, and relevance between serum prealbumin and serum albumin, cholesterol, cholinesterase, total bile acids, prothrombin time, Child-Turcotte-Pugh, and model of end-stage liver stage.

Different independent susceptibility markers for first-ever cerebral infarction and myocardial infarction in young patients

Cerebral infarction (CI) and myocardial infarction (MI) share some common features, but there are other differences in risk factors. The aim of our study is to determine whether there are some significantly independent susceptibility markers for them. All consecutive patients between the ages of 18 and 45 years with first-ever CI and MI during 2001-2010 were recruited to participate in the study. Using multivariate logistic regression modeling, we explore many different data, such as age at onset, sex ratio, numbers of patients with history of hypertension, smoking, drinking, and serum lipid, uric acid, prealbumin (PA), and white blood cell (WBC) count levels. Logistic regression analysis adjusted for confounders confirmed the following independent susceptibility markers for young CI patients: hypertension, admission serum PA levels, daily alcohol [odds ratio (OR), 0.251; 95% confidence interval (CI), 0.097-0.648, p = 0.004; OR, 0.994; 95% CI, 0.988-0.999, p = 0.031; OR, 0.150; 95% CI, 0.047-0.473, p = 0.001], and for MI patients: age at onset, current smoking, serum WBC, and glucose levels (OR, 1.293; 95% CI, 1.146-1.457, p = 0.000; OR, 8.914; 95% CI, 3.575-22.231, p = 0.000; OR, 1.344; 95% CI, 1.169-1.544, p = 0.000; OR, 1.149; 95% CI, 1.022-1.291, p = 0.020). We conclude that there are some significantly different independent susceptibility markers for young CI and MI patients.

Malnutrition in patients with acute stroke

Stroke is a devastating event that carries a potential for long-term disability. Malnutrition is frequently observed in patients with stroke, and dysphagia contributes to malnutrition risk. During both the acute phase of stroke and rehabilitation, specific nutritional interventions in the context of a multidisciplinary team effort can enhance the recovery of neurocognitive function. Early identification and management of malnutrition with dietary modifications or specific therapeutic strategies to ensure adequate nutritional intake should receive more attention, since poor nutritional status appears to exacerbate brain damage and to contribute to adverse outcome. The main purpose of nutritional intervention should be the prevention or treatment of complications resulting from energy-protein deficit. This paper reviews the evaluation and management of malnutrition and the use of specialized nutrition support in patients with stroke. Emphasis is given to enteral tube and oral feeding and to strategies to wean from tube feeding.