Serum Uric Acid - Risk Factor for Acute Ischemic Stroke and Poor Outcomes

Serum uric acid as a predictor of mortality in patients with stroke: results from National Health and Nutrition Examination Survey 2007-2016

Objective

This research endeavors to explore the relationship between serum uric acid (SUA) concentration and all-cause mortality in stroke patients.

Methods

We undertook a cross-sectional analysis utilizing data derived from the National Health and Nutrition Examination Survey (NHANES) spanning 2007 to 2016. The concentrations of SUA served as the independent variable, while the dependent variable was defined as all-cause mortality in stroke patients. The quartile method was utilized to classify uric acid levels into four distinct categories. Subsequently, three models were developed, and Cox proportional hazards regression was used to assess the effect of varying uric acid concentrations on the risk of all-cause mortality among stroke patients.

Results

The study included a total of 10,805 participants, of whom 395 were stroke patients. Among all populations, the group with elevated levels of uric acid (Q4) exhibited a significant association with the overall mortality risk among stroke patients in all three models (model 1 p < 0.001, model 2 p < 0.001, model 3 p < 0.001). In the male population, there was no significant correlation observed between uric acid levels and the overall mortality risk among stroke patients in model 3 (Q2 p = 0.8, Q3 p = 0.2, Q4 p = 0.2). However, within the female population, individuals with high uric acid levels (Q4) demonstrated a noteworthy association with the overall mortality risk among stroke patients across all three models (model 1 p < 0.001, model 2 p < 0.001, model 3 p < 0.001).

Conclusion

This cross-sectional investigation reveals a significant correlation between SUA levels and all-cause mortality in stroke patients, with a noticeable trend observed among females. Consequently, SUA may serve as a promising biomarker for assessing the prognosis of individuals affected by stroke.

The paradigm change from reactive medical services to 3PM in ischemic stroke: a holistic approach utilising tear fluid multi-omics, mitochondria as a vital biosensor and AI-based multi-professional data interpretation

Worldwide stroke is the second leading cause of death and the third leading cause of death and disability combined. The estimated global economic burden by stroke is over US$891 billion per year. Within three decades (1990-2019), the incidence increased by 70%, deaths by 43%, prevalence by 102%, and DALYs by 143%. Of over 100 million people affected by stroke, about 76% are ischemic stroke (IS) patients recorded worldwide. Contextually, ischemic stroke moves into particular focus of multi-professional groups including researchers, healthcare industry, economists, and policy-makers. Risk factors of ischemic stroke demonstrate sufficient space for cost-effective prevention interventions in primary (suboptimal health) and secondary (clinically manifested collateral disorders contributing to stroke risks) care. These risks are interrelated. For example, sedentary lifestyle and toxic environment both cause mitochondrial stress, systemic low-grade inflammation and accelerated ageing; inflammageing is a low-grade inflammation associated with accelerated ageing and poor stroke outcomes. Stress overload, decreased mitochondrial bioenergetics and hypomagnesaemia are associated with systemic vasospasm and ischemic lesions in heart and brain of all age groups including teenagers. Imbalanced dietary patterns poor in folate but rich in red and processed meat, refined grains, and sugary beverages are associated with hyperhomocysteinaemia, systemic inflammation, small vessel disease, and increased IS risks. Ongoing 3PM research towards vulnerable groups in the population promoted by the European Association for Predictive, Preventive and Personalised Medicine (EPMA) demonstrates promising results for the holistic patient-friendly non-invasive approach utilising tear fluid-based health risk assessment, mitochondria as a vital biosensor and AI-based multi-professional data interpretation as reported here by the EPMA expert group. Collected data demonstrate that IS-relevant risks and corresponding molecular pathways are interrelated. For examples, there is an evident overlap between molecular patterns involved in IS and diabetic retinopathy as an early indicator of IS risk in diabetic patients. Just to exemplify some of them such as the 5-aminolevulinic acid/pathway, which are also characteristic for an altered mitophagy patterns, insomnia, stress regulation and modulation of microbiota-gut-brain crosstalk. Further, ceramides are considered mediators of oxidative stress and inflammation in cardiometabolic disease, negatively affecting mitochondrial respiratory chain function and fission/fusion activity, altered sleep-wake behaviour, vascular stiffness and remodelling. Xanthine/pathway regulation is involved in mitochondrial homeostasis and stress-driven anxiety-like behaviour as well as molecular mechanisms of arterial stiffness. In order to assess individual health risks, an application of machine learning (AI tool) is essential for an accurate data interpretation performed by the multiparametric analysis. Aspects presented in the paper include the needs of young populations and elderly, personalised risk assessment in primary and secondary care, cost-efficacy, application of innovative technologies and screening programmes, advanced education measures for professionals and general population-all are essential pillars for the paradigm change from reactive medical services to 3PM in the overall IS management promoted by the EPMA.

Mean Platelet Volume/Platelet Count Ratio as a Predictor of Both Incidence and Prognosis of Acute Ischemic Stroke in Hemodialysis Patients

Purpose

This study aimed to explore whether the mean platelet volume/platelet count ratio (MPR) has predictive value for the occurrence and prognosis of acute ischemic stroke (AIS) in hemodialysis patients.

Patients and Methods

A total of 402 patients undergoing maintenance hemodialysis were screened and 259 were enrolled in this study. The receiver operating characteristic curve and area under the curve (AUC) were used to evaluate the predictive power of the models. The patients enrolled in this study were divided into three groups based on the tertiles of the MPR value (Q1, Q2, and Q3). Kaplan-Meier curves were used to investigate the association between the MPR and AIS-free survival in hemodialysis patients. Chi-square analysis was performed to explore the association between the MPR and AIS outcomes in hemodialysis patients. And the AIS outcome was assessed using the modified Rankin Scale (mRS).

Results

MPR had a predictive value for the occurrence of AIS (AUC=0.814) in hemodialysis patients with a high sensitivity and specificity. AIS-free survival rates in the MPR Q1, MPR Q2, and MPR Q3 groups were 0.930, 0.701, and 0.360, respectively. The proportion of patients with good outcomes (mRS 0-2) was significantly greater among patients in the MPR Q1-Q2 group than in the MPR Q3 group (0.844 vs 0.745, p <0.001).

Conclusion

The MPR can be used as a good predictor of AIS in patients undergoing hemodialysis. Patients on hemodialysis with increased MPR levels had a higher incidence of AIS and poorer functional outcomes than those with low MPR levels.

The association between serum uric acid and cognitive performance in patients with ischemic stroke is modified by estimated glomerular filtration rate

The relationship between serum uric acid (SUA) and poor cognitive performance in patients with ischemic stroke is unclear. We hypothesized that the severity of renal function mediates the association between SUA and cognitive dysfunction.A retrospective analysis of 608 patients with ischemic stroke was conducted between 2016 and 2020. SUA was obtained from inpatient medical records. Global cognitive function via mini-mental state exam (MMSE) and Montreal Cognitive Assessment (MoCA) was determined one month after hospital discharge. The relationship between SUA and cognitive function was assessed by multiple linear and logistic regression analyses. Patients had a mean age of 66.6 years (SD: 4.1 years), and 52% were male. The mean SUA level was 298.6 ± 75.4 μmol/L. SUA increases were significantly positively associated with lower MMSE and MoCA scores and increased risk of moderate-severe cognitive impairment one month after stroke (p < 0.01), even after adjusting for factors including age, gender, BMI, diabetes and hypertension history. Adding a term for estimated glomerular filtration rate (eGFR) attenuated these associations such that SUA was no longer associated with cognitive performance. A fully adjusted stronger negative association between SUA and cognitive performance was found in those who had lower eGFR, with a significant eGFR interaction for MMSE (p-interaction = 0.016) and MoCA (p-interaction = 0.005). In patients with ischemic stroke, SUA showed an inverse association with cognitive function among those who have lower eGFR. The renal function might mediate the association between SUA and cognitive dysfunction.

J-Shaped Relationship of Serum Uric Acid with Unfavorable Short-Term Outcomes among Patients with Acute Ischemic Stroke

(1) Background: The role of uric acid in stroke outcomes remains inconclusive. (2) Methods: We retrospectively enrolled 3370 patients with acute ischemic stroke. (3) Results: Uric acid level was higher in men than in women. Univariate analyses revealed that the rates of hyperuricemia were higher in all patients and in women for unfavorable outcomes. For death, the hyperuricemia rates were higher in all patients including men and women, and the uric acid levels were also higher in all patients and in women. A J-shaped curve was observed between uric acid and the discharge-modified Rankin Scale score. Patients within Quartiles 1 (<4.1 mg/dL) and 4 (>6.5 mg/dL) of uric acid had higher rates of unfavorable outcomes and death than patients within Quartiles 2 (4.1−5.1 mg/dL) and 3 (5.1−6.2 mg/dL). Multivariable analyses for unfavorable outcomes revealed that Quartile 1 of uric acid was a significant factor in all patients and in men. In men, a significant factor for death was being in Quartile 1 of uric acid. In women, higher levels of uric acid or hyperuricemia (>6.6 mg/dL) were significant factors for death. (4) Conclusions: Lower uric acid levels are a predictor for unfavorable outcomes and death in men, and higher uric acid levels are a predictor for death in women.

Uric Acid and Clinical Outcomes in Young Patients with Ischemic Stroke

BACKGROUND AND PURPOSE

There is limited available evidence for the relationship between uric acid (UA) levels and ischemic stroke in young adults. We aimed to explore the association between UA levels and acute ischemic stroke (AIS) in young patients.

MATERIALS AND METHODS

This was a prospective and observational study. We recruited young patients aged 18-45 years with AIS at our tertiary hospital. Patients were categorized into four groups according to quartiles of UA levels. The primary outcome was functional outcome at 3 months. The secondary outcomes included stroke severity, in-hospital complications, and functional outcome at discharge. Modified Rankin Scale (mRS) scores were used to assess functional outcome as poor (mRS=2-6) or favorable(mRS=0-1).

RESULTS

A total of 636 patients were enrolled in the current analysis. The four groups were defined as follows: Q1≤289.8 µmol/L, 289.8 µmol/ L<Q2≤349.0 µmol/L, 349.0 µmol/L<Q3≤421 µmol/L, and Q4>421 µmol/L. Multiple logistic regression analysis showed that UA levels were not significantly predictive of functional outcome either at discharge or at 3 months after AIS. However, compared to Q1, higher UA levels were significantly negatively associated with the rate of moderate-severe stroke (NIHSS≥5) at admission (p for trend =0.016). Furthermore, a reduction in the risk for in-hospital pneumonia was significantly associated with higher UA levels compared to Q1 (P for trend < 0.0001).

CONCLUSION

Serum UA was a protective factor for stroke severity and in-hospital pneumonia after AIS in young patients. However, we were unable to identify the predictive significance of UA for functional outcome either at discharge or at 3 months after AIS.

Hyperuricemia and Its Association With Ischemic Stroke

Elevated serum uric acid (SUA) levels have been associated with an increased risk of cardiovascular (CV) disease and acute ischemic stroke (AIS) as well as many other medical conditions. AIS is a CV complication that is the second most common cause of mortality worldwide. It results from reduced blood flow to the brain by means of thrombosis, embolism, or systemic hypoperfusion. Studies have demonstrated an association between SUA levels and CV events, with a significant dose-response relationship between elevated SUA levels and stroke risk. Since the relationship between SUA levels and AIS risk has been established, studies are also being conducted in order to evaluate whether antihyperuricemic drugs can lower this risk. Allopurinol use in hyperuricemic patients has been shown to decrease the risk of major CV events, which include AIS. This narrative review aims to investigate the role of SUA as an independent risk factor for AIS along with the proposed biological mechanisms by thoroughly appraising research findings from relevant full-text articles and abstracts indexed in PubMed and the Cochrane Library. In this literature, we will be discussing hyperuricemia, AIS, the association between the two, and the use of antihyperuricemic medications on stroke prognosis. This review will also shed new light on studies that have begun to provide insight into the predictive role of hyperuricemia in AIS.

The Prognostic Value of Serum Uric Acid in Hospitalized Patients with Acute Cerebral Infarction

Background

Previous studies reported that the level of serum uric acid (SUA) was an important risk factor for acute cerebral infarction (ACI). However, the prognostic value of SUA levels in hospitalized patients with ACI has not been fully elucidated. The aim of this study was to investigate whether the SUA level on admission was associated with subsequent mortality in hospitalized patients with ACI.

Methods

The clinical data of ACI patients obtained from December 2017 to December 2019 were retrospectively reviewed. χ² and Kaplan–Meier methods were used to compare the clinical differences and overall survival between patients with or without hyperuricemia, respectively. Univariate and multivariate analyses were used to identify independent prognoses.

Results

In the total population, the in-hospital mortality of the hyperuricemia group was significantly higher than that of the normal uric acid group (P = 0.006). In the abnormal renal function group, the in-hospital mortality among the hyperuricemia group was significantly higher than the normal uric acid group (P = 0.002). However, there was no statistical difference of in-hospital mortality between the two groups in the normal renal function group (P = 0.321). Univariate and multivariate analyses showed that a previous history of diabetes (P = 0.018), hyperuricemia (P = 0.001), and National Institutes of Health Stroke Scale (NIHSS) score on admission (P ≤ 0.001) were independent factors for all samples. The hyperuricemia (P = 0.003) on admission were independent factors for patients with abnormal renal function.

Conclusions

In ACI patients with abnormal renal function, hyperuricemia may be associated with higher in-hospital mortality than patients with normal uric acid, and hyperuricemia may be an independent associated factor for in-hospital death in the subgroup patients.

The Relationship Between Elevated Serum Uric Acid and Risk of Stroke in Adult: An Updated and Dose-Response Meta-Analysis

Background: Uric acid (UA) is proposed as a potential risk factor for stroke in adult, yet the results from published studies are not generally accordant.

Method: We included prospective studies that explored the relationship between serum UA (SUA) and strokes. In this study, strokes include ischemic stroke and hemorrhagic stroke, which consists of intracerebral hemorrhage and subarachnoid hemorrhage. The effect-size estimates were expressed as hazard ratio (HR) and 95% confidence interval (CI). Sensitivity and subgroup analyses were performed to assess the robustness of the pooled estimation and potential sources of heterogeneity between studies.

Results: We meta-analyzed 19 prospective cohort articles, which involve 37,386 males and 31,163 females. Overall analyses results showed a significant association between a 1 mg/dl increase in high levels of SUA and the risk of total stroke (HR = 1.13; 95% CI: 1.09–1.18; P < 0.001), ischemic stroke (HR = 1.15; 95% CI: 1.10–1.21; P < 0.001), and hemorrhagic stroke (HR = 1.07; 95% CI: 1.00 to 1.15; P = 0.046). No significant difference was found between ischemic stroke and hemorrhagic stroke. In the subgroup analyses, the association of high SUA levels and the risk of total stroke was statistically significant in females (HR = 1.19; 95% CI: 1.12–1.26; P < 0.001) and males (HR = 1.11; 95% CI: 1.05–1.17; P < 0.001). Coincidentally, the association was also statistically significant for ischemic stroke, both in females (HR = 1.26; 95% CI: 1.17–1.36; P < 0.001) and in males (HR = 1.12; 95% CI: 1.06–1.19; P < 0.001). However, for hemorrhagic stroke, it was only statistically significant in females (HR = 1.19; 95% CI: 1.04–1.35; P = 0.01). Our dose–response research indicated the J-shaped trend between the ascending SUA levels and the higher risk of suffering from a stroke.

Conclusions: Our findings indicate that elevated SUA is a significant risk factor for adult stroke, both for ischemic stroke and hemorrhagic stroke, and especially in females.

Characteristics of ischemic stroke and intracranial hemorrhage in patients with nephrotic syndrome

BACKGROUND

The incidence of cerebral stroke, including ischemic infarction and intracranial hemorrhage (ICH), increases in patients with nephrotic syndrome (NS). However, the clinical characteristics of patients with NS and stroke remain elusive. We aimed to investigate the clinical presentation and prognosis among patients with NS and ischemic stroke (IS) or ICH.

METHODS

We conducted a population-based retrospective cohort study of patients with NS and acute stroke using the Chang Gung Research Database of Taiwan from January 1, 2001, to December 31, 2017. The participants were recruited from the 7 branches of Chang Gung Memorial Hospital.

RESULTS

A total of 233 patients with IS and 57 patients with ICH were enrolled. The median age was 60 (52-70) years. The prevalence rates of hyperlipidemia, hyperuricemia, and smoking were higher in IS than in ICH. IS demonstrated lower white blood cell count (7.80 vs. 8.92 × 10⁹/L) and high-sensitivity C-reactive protein level (33.42 vs. 144.10 nmol/L) and higher cholesterol (5.74 vs. 4.84 mmol/L), triglyceride (1.60 vs. 1.28 mmol/L), and albumin (24 vs. 18 g/L) levels compared with ICH. The dependent functional status and 30-day mortality were higher in ICH than in IS. The risk factors for 30-day mortality for patients with NS and stroke were coronary artery disease (CAD), ICH, and total anterior circulation syndrome. The multivariate Cox regression analysis revealed that CAD was positively associated with 30-day mortality in patients with IS (hazard ratio 24.58, 95 % CI 1.48 to 408.90). In patients with ICH, CAD and subarachnoid hemorrhage were positively associated with 30-day mortality (hazard ratio 5.49, 95 % CI 1.54 to 19.56; hazard ratio 6.32, 95 % CI 1.57 to 25.53, respectively).

CONCLUSIONS

ICH demonstrated a higher risk of dependence and 30-day mortality compared with IS in patients with NS. Intensive monitoring and treatment should be applied particularly in patients with NS and ICH.

Gender Differences in the Association Between Serum Uric Acid and Arteriosclerotic Cardiovascular Risk Among Chinese Type 2 Diabetes Mellitus Patients

Background and Objectives

Serum uric acid (sUA) level has been reported to be associated with arteriosclerotic cardiovascular risk, yet remains poorly defined in Chinese type 2 diabetes patients. The purpose of the current study was to evaluate gender differences in the association between sUA level and arteriosclerotic cardiovascular risk in Chinese type 2 diabetes patients.

Methods

The cross-sectional study was conducted in six community health service centers in Shanghai, China from December 2014 to December 2016. A stratified random sampling method was used to recruit participants. From a total of 3977 type 2 diabetic patients, 2537 were included for the analysis of the association between sUA level and arteriosclerotic cardiovascular risk. Clinical and biochemical data were obtained from participants. Arteriosclerotic cardiovascular risk was evaluated by the ten-year risk profile for arteriosclerotic cardiovascular disease. The associations between sUA level and arteriosclerotic cardiovascular risk were assessed via multiple logistic regression.

Results

Of the 2537 participants, the average sUA level was 317±77umol/L in men and 294±73 umol/L in women, and 54.8% (1391/2537) of participants had high ten-year risk of arteriosclerotic cardiovascular disease (ASCVD), which was ≥20%. High ten-year risk of ASCVD odds ratio was increased by 1.596 (95% CI, 1.113-2.289, p for trend 0.004) comparing fourth to first quartiles of sUA in women. However, no significant association was found between sUA and high ten-year risk of ASCVD in men.

Conclusion

This community-based study indicated that sUA levels were independently associated with high ten-year risk of ASCVD in women with type 2 diabetes mellitus, but not in men.

Why Does Hyperuricemia Not Necessarily Induce Gout?

Hyperuricemia is a risk factor for gout. It has been well observed that a large proportion of individuals with hyperuricemia have never had a gout flare(s), while some patients with gout can have a normuricemia. This raises a puzzle of the real role of serum uric acid (SUA) in the occurrence of gout flares. As the molecule of uric acid has its dual effects in vivo with antioxidant properties as well as being an inflammatory promoter, it has been placed in a delicate position in balancing metabolisms. Gout seems to be a multifactorial metabolic disease and its pathogenesis should not rely solely on hyperuricemia or monosodium urate (MSU) crystals. This critical review aims to unfold the mechanisms of the SUA role participating in gout development. It also discusses some key elements which are prerequisites for the formation of gout in association with the current therapeutic regime. The compilation should be helpful in precisely fighting for a cure of gout clinically and pharmaceutically.

Higher uric acid is associated with better discharge recovery and short-term outcome in stroke patients treated with thrombolysis

BACKGROUND

Uric acid (UA) possesses antioxidant features and potential neuroprotective effects. However, conflicting results regarding the association between serum uric acid (SUA) levels and the prognosis of stroke have been obtained. We aimed to assess whether SUA is related to discharge recovery and short-term outcomes in patients who underwent thrombolysis therapy.

METHODS

We recruited 393 consecutive patients who were diagnosed with acute ischaemic stroke (AIS) and treated with thrombolysis. The demographic information, including sex and age, was collected. Haematology tests, including SUA, fasting plasma glucose (FPG), and blood lipid parameters, were performed under fasting conditions the morning after admission. The modified Rankin Scale (mRS) was used to assess the functional outcome of patients at discharge and 3 months after onset.

RESULTS

A negative correlation was observed between the levels of SUA and the National Institute of Health Stroke Scale (NIHSS) score at discharge (r = - 0.171, P = 0.003). Additionally, a positive correlation was observed between the levels of SUA and the difference between the baseline NIHSS and discharge NIHSS (r = 0.118, P = 0.032). The levels of SUA in the patients with good outcomes (353.76 ± 93.05) were higher than those in the patients with poor outcomes (301.99 ± 92.24; P = 0.015) at 3 months. The multivariate logistic regression analysis demonstrated that a higher SUA level (odds ratio 0.988, 95% confidence interval 0.985-0.991, P = 0.002) was an independent predictor of a good outcome at 3 months.

CONCLUSION

Higher SUA levels were associated with better discharge recovery and 3-month outcomes in patients with ischaemic stroke who received thrombolysis.