Elevated lactate dehydrogenase predicts poor prognosis of acute ischemic stroke

Lactate dehydrogenase to albumin ratio and poor prognosis after thrombolysis in ischemic stroke patients: developing a novel nomogram

BACKGROUND

Ischemic stroke (IS) is associated with high disability and mortality. This study aimed to identify the prognostic predictors and develop a nomogram for a prediction model for ischemic stroke patients after thrombolysis.

METHODS

We retrospectively analyzed data from 359 IS patients who underwent thrombolysis. Clinical characteristics, laboratory parameters, and prognosis data were collected. One-third of the subjects were randomly selected as a validation set (n = 108) for internal validation. Logistic regression analysis was used to derive independent risk indicators. A nomogram was constructed using these indicators, and the performance of the nomogram was assessed by the Area Under the Curve (AUC) of the Receiver Operating Characteristic (ROC). The agreement of the model predictions with actual observations was assessed via calibration curves, and the clinical utility of the nomogram was assessed via decision curve analysis.

RESULTS

Multivariate logistic regression analysis showed that age, leukocytes, Lactate Dehydrogenase to Albumin Ratio (LAR) and NIHSS were independent predictors of three-month post-thrombolysis prognosis in IS patients. We created a nomogram based on the weighting coefficients of these factors. The AUC curves showed that our model including age, leukocytes, LAR and NIHSS was more accurate in predicting prognosis than a single factor. The calibration curves showed a good fit between actual and predicted probabilities in both the training and validation groups.

CONCLUSION

LAR has a good predictive power for the prognosis of IS patients 3 months after thrombolytic therapy and can be used as a new clinical indicator to establish a practical nomogram.

Nomogram to predict 3 month prognosis of acute ischemic stroke among young adults

Objective

This study aimed to develop and validate a nomogram for predicting the risk of 3 months adverse outcomes among young adults with acute ischemic stroke (AIS).

Methods

Patients aged between 18 and 50 with acute ischemic stroke (AIS) at the Shenyang First's People Hospital, between January 1st 2017 to May 30th 2023 were included in this retrospective study. The primary outcome was a three-month unfavorable outcome, evaluated with modified Rankin Scale (mRS > 2). Univariate logistic regression was used to select the independent factors of prognosis and multivariate logistic regression to establish a new nomogram model. We used the area under the receiver-operating characteristic curve (ROC) to evaluate the discriminative performance and used the calibration curve with Hosmer-Lemeshow goodness of fit test to assess the calibration performance of the risk prediction model. Decision curve analysis (DCA) was applied to assess the clinical utility of the nomogram.

Results

A total of 1,015 patients were enrolled. Gender (male vs. female; Odds ratio[OR], 0.5562[95% Confidence Interval (CI), 0.3104-1.0478]; p = 0.053), family history of stroke (OR, 3.5698[95%CI 1.5632-8.0329], p < 0.001), prior stroke (OR, 2.1509[95%CI 1.2610-3.6577], p < 0.001), previous heart disease (OR, 3.4047[95%CI, 1.7838-6.6976], p < 0.01) toast type (cardio-embolism stroke vs. large-artery atherosclerosis (LAA), OR, 0.0847[0.0043-0.5284], p < 0.01), toast type (stroke of undetermined etiology vs. LAA, OR, 0.0847[0.0439-0.5284], p < 0.01), mRS at admission (OR, 15.2446 [9.1447-26.3156], p < 0.0001), adherence to medication (OR, 2.1197[95%CI, 1.1924-3.7464], p < 0.001), systolic blood pressure (SBP; OR, 1.0145[1.0041-1.0250], p < 0.001), and lactate dehydrogenase (LDH; OR, 1.0060[1.0010-1.0111], p < 0.01) were related to 3 months adverse outcomes among young adults with AIS. The nomogram displayed excellent calibration and discrimination. DCA confirmed the clinical applicability of the model.

Conclusion

The nomogram comprised of gender, family history of stroke, prior stroke, previous heart disease, toast type, mRS score at admission, adherence to medication, SBP and LDH may predict 3 months adverse outcomes among young adults with AIS.

Serum Level of RIPK1/3 Correlated With the Prognosis in ICU Patients With Acute Ischemic Stroke

BACKGROUND

Acute ischemic stroke (AIS) is a common cerebrovascular disease with high mortality. AIS patients in the intensive care unit (ICU) often have severe conditions that require close monitoring and timely treatment. Receptor-interacting protein kinase 1 (RIPK1) and RIPK3 play important roles in cell apoptosis and inflammation. However, the relevance of serum RIPK1/3 to AIS patients in the ICU has not been clarified.

OBJECTIVE

To explore the correlation of serum RIPK1 and RIPK3 with the prognosis of AIS patients in the ICU.

METHODS

One hundred and twenty AIS patients were selected as the research subjects for the retrospective analysis. The subjects were grouped based on the volume of cerebral infarction and the score of the National Institute of Health Stroke Scale (NIHSS) and mRS. The correlation was explored using Pearson analysis. The predictive value was valued using the ROC curve.

RESULTS

The content of serum RIPK1 and RIPK3 was gradually elevated with increased cerebral infarction volume and the severity of the disease (p < 0.05). Patients with poor prognosis had a higher content of serum RIPK1 and RIPK3 than those with good prognosis (p < 0.05). Serum RIPK1 and RIPK3 levels were positively correlated with infarct volume, NHISS, and mRS scores (p < 0.001). The area under the curve (AUC) of RIPK1 and RIPK3 for predicting the severity of AIS was 0.703, 0.883, and 0.912, respectively. The AUC for predicting poor prognosis of AIS was 0.797, 0.721, and 0.893, respectively. The cooperative detection of RIPK1 and RIPK3 had higher clinical value.

CONCLUSION

AIS patients in the ICU had abnormally elevated content of serum RIPK1 and RIPK3, which was closely related to the volume of cerebral infarction, severity, and prognosis. Combined detection of RIPK1 and RIPK3 might help to early identify the severity and evaluate the prognosis, providing a reference basis for clinical doctors to develop treatment strategies.

Progress in Lactate Metabolism and Its Regulation via Small Molecule Drugs

Lactate, once viewed as a byproduct of glycolysis and a metabolic "waste", is now recognized as an energy-providing substrate and a signaling molecule that modulates cellular functions under pathological conditions. The discovery of histone lactylation in 2019 marked a paradigm shift, with subsequent studies revealing that lactate can undergo lactylation with both histone and non-histone proteins, implicating it in the pathogenesis of various diseases, including cancer, liver fibrosis, sepsis, ischemic stroke, and acute kidney injury. Aberrant lactate metabolism is associated with disease onset, and its levels can predict disease outcomes. Targeting lactate production, transport, and lactylation may offer therapeutic potential for multiple diseases, yet a systematic summary of the small molecules modulating lactate and its metabolism in various diseases is lacking. This review outlines the sources and clearance of lactate, as well as its roles in cancer, liver fibrosis, sepsis, ischemic stroke, myocardial infarction, and acute kidney injury, and summarizes the effects of small molecules on lactate regulation. It aims to provide a reference and direction for future research.

Cardiac biomarkers are associated with increased risks of adverse clinical outcomes after ischemic stroke

BACKGROUND

Impaired cardiac function was suggested to be implicated in the functional recovery after ischemic stroke, but the prognostic value of cardiac biomarkers among ischemic stroke patients remains unclear. We aimed to prospectively explore the associations of serum lactate dehydrogenase (LDH), plasma N-terminal pro-brain natriuretic peptide (NT-proBNP), and plasma high-sensitivity cardiac troponin T (hs-cTnT) with adverse clinical outcomes after ischemic stroke in a large-scale cohort study.

METHODS

We measured serum LDH, plasma NT-proBNP, and plasma hs-cTnT levels at baseline among 5056 ischemic stroke patients from the Minhang Stroke Cohort study. All patients were followed up at 3 months after ischemic stroke onset. The primary outcome was composite outcome of death and major disability (modified Rankin Scale [mRS] score ≥ 3) at 3 months after stroke onset, and secondary outcomes included death and ordered 7-level categorical score of the mRS.

RESULTS

During 3 months of follow-up, 1584 patients developed the primary outcome. Baseline serum LDH, plasma NT-proBNP, and plasma hs-cTnT were positively associated with the risk of adverse outcomes after ischemic stroke. The multivariable-adjusted odds ratios of primary outcome for the highest versus lowest quartile of LDH, NT-proBNP, and hs-cTnT were 1.37 (95% CI 1.13-1.66; Ptrend = 0.001), 2.51 (95% CI, 2.00-3.16; Ptrend < 0.001), and 2.24 (95% CI 1.77-2.83; Ptrend < 0.001), respectively. Each SD increase of log-transformed cardiac biomarker score was associated with a 49% (95% CI 37-62%; P < 0.001) increased risk of primary outcome. Multivariable-adjusted spline regression analyses showed linear relationships between cardiac biomarkers and the risk of primary outcome (all P for linearity < 0.001). Moreover, adding LDH, NT-proBNP, hs-cTnT, or cardiac biomarker score to conventional risk factors significantly improved the risk reclassification of primary outcome after ischemic stroke (all P < 0.05).

CONCLUSION

High LDH, NT-proBNP, hs-cTnT, and cardiac biomarker score were independently associated with increased risks of adverse clinical outcomes among ischemic stroke patients, suggesting that cardiac biomarkers might be potential prognostic biomarkers for ischemic stroke.

Mediation effect of stroke recurrence in the association between post-stroke lactate dehydrogenase and functional disability

Background

We aimed to use lactate dehydrogenase (LDH) as a marker of inflammation burden and quantify post-stroke inflammation's direct and indirect effect on functional disability.

Methods

We analyzed 5,129 patients with acute ischemic stroke (AIS) admitted to Shenyang First People's Hospital. Stroke recurrence and functional outcome measured by the modified Rankin Scale (mRS) were assessed at 90 days. Functional disability was defined as mRS score > 2. Receiver operating characteristic curve and restricted cubic spline (RCS) analysis were conducted to illustrate the associations between LDH levels and 90-day functional outcomes in patients with AIS. Mediation analyses were performed to examine the potential causal chain in which stroke recurrence may mediate the relationship between LDH and functional outcome. Positive correlation between LDH and hs-CRP was found and mediation effects of stroke recurrence in the association between LDH or hs-CRP and functional disability were both less than 20%. Sensitivity analyses in different subgroups showed comparable results.

Results

Among 5,129 included AIS patients, the median (IQR) level of LDH was 186 (161-204.4) U/L. Functional disability was seen in 1200 (23.4%) patients and recurrence was observed in 371(7.2%) patients at 90-day follow-up. Each standard deviation increase in the concentration of LDH was linked to an increased risk of functional disability (adjusted odds ratio[aOR], 1.07; 95%CI,1.04-1.09) and stroke recurrence (aOR,1.02; 95%CI, 1.01-1.04) within 90 days. The highest quartile of LDH (>204.2 U/L) had an elevated risk of suffering functional disability (aOR, 1.21; 95%CI, 1.00-1.47) and recurrence (aOR, 1.21; 95%CI,1.00-1.47) compared with the lowest quartile of LDH (<161 U/L). Stroke recurrence during follow-up explained 12.90% (95%CI, 6.22-21.16%) of the relationship between LDH and functional disability. Positive correlation between LDH and hs-CRP was found and mediation effects of recurrence in the association between LDH or hs-CRP and functional disability were both less than 20%. Sensitivity analyses in different subgroups showed comparable results.

Conclusion

The relationship between LDH and functional disability at 90 days among AIS patients is partially mediated by stroke recurrence, accounting for less than 20%. LDH deserves equal attention as hs-CRP in predicting recurrence and functional outcome. In addition to traditional secondary prevention measures, innovative anti-inflammatory strategies warrant further investigation.

Integrated analysis of single cell-RNA sequencing and Mendelian randomization identifies lactate dehydrogenase B as a target of melatonin in ischemic stroke

AIMS

Despite the success of single-cell RNA sequencing in identifying cellular heterogeneity in ischemic stroke, clarifying the mechanisms underlying these associations of differently expressed genes remains challenging. Several studies that integrate gene expression and gene expression quantitative trait loci (eQTLs) with genome wide-association study (GWAS) data to determine their causal role have been proposed.

METHODS

Here, we combined Mendelian randomization (MR) framework and single cell (sc) RNA sequencing to study how differently expressed genes (DEGs) mediating the effect of gene expression on ischemic stroke. The hub gene was further validated in the in vitro model.

RESULTS

We identified 2339 DEGs in 10 cell clusters. Among these DEGs, 58 genes were associated with the risk of ischemic stroke. After external validation with eQTL dataset, lactate dehydrogenase B (LDHB) is identified to be positively associated with ischemic stroke. The expression of LDHB has also been validated in sc RNA-seq with dominant expression in microglia and astrocytes, and melatonin is able to reduce the LDHB expression and activity in vitro ischemic models.

CONCLUSION

Our study identifies LDHB as a novel biomarker for ischemic stroke via combining the sc RNA-seq and MR analysis.

High serum lactate dehydrogenase to albumin ratio is associated with increased risk of poor prognosis after ischemic stroke

BACKGROUND

Lactate dehydrogenase to albumin ratio (LAR) is a comprehensive biomarker for anaerobiosis, inflammation, and nutritional status, but its prognostic value for ischemic stroke has rarely been reported. We aimed to prospectively investigate whether serum LAR is associated with the prognosis of ischemic stroke patients in a large-scale cohort study.

MATERIALS AND METHODS

Serum LAR levels were measured among 6634 patients with ischemic stroke admitted at Minhang hospital from January 2018 to December 2022. The primary outcome was the composite of major disability and death (modified Rankin Scale score [mRS] ≥ 3) at 3-month follow up. Secondary outcomes included death and the ordered 7-level category score of mRS. Multivariate logistic regression and restricted cubic splines were adopted to evaluate the associations between serum LAR levels and adverse clinical outcomes of ischemic stroke.

RESULTS

During 3 months of follow-up period, a total of 2125 patients experienced primary outcome. After multivariate adjustment, the highest quartile of serum LAR was associated with an increased risk of primary outcome (odds ratio [OR], 1.52; 95% confidence interval [CI], 1.27-1.83; P for trend < 0.001). Each standard deviation higher log-transformed serum LAR resulted in a 20% (95% CI, 12%-28%) increased risk of primary outcome. Furthermore, multivariable-adjusted restricted cubic spline analyses showed a linear association between the serum LAR level with primary outcome (P for linearity < 0.001). Finally, the addition of serum LAR to conventional risk factors significantly improved risk predictive abilities for the primary outcome (net reclassification improvement [NRI]: 18.35%, P < 0.001; integrated discrimination improvement [IDI]: 0.35%, P < 0.001) at 3-month follow up in patients with ischemic stroke.

CONCLUSION

High serum LAR level was independently associated with an increased risk of adverse clinical outcomes among patients with ischemic stroke, indicating that serum LAR may be a valuable prognostic biomarker for ischemic stroke.

Causal relationship between lactate dehydrogenase and risk of developing ischemic stroke: A Mendelian randomized study

BACKGROUND AND OBJECTIVE

Ischemic stroke (IS) is one of the major global health problems. It is not clear whether there is a causal relationship between lactate dehydrogenase (LDH) and the risk of IS attacks. The purpose of this study was to investigate whether LDH has a causal relationship with the development of IS.

METHODS

The genome-wide association data of LDH and IS were obtained through a Mendelian randomization-based platform. Single nucleotide polymorphisms (SNP) that were significantly associated with LDH were identified and used as instrumental variables, and a two-sample Mendelian randomization study was used to examine the causal relationship between LDH and IS. The statistical methods included Inverse-variance weighted approach, MR-Egger regression, and weighted median estimator.

RESULTS

We selected 15 SNPs of genome-wide significance from Genome-wide association study database with LDH as instrumental variables. A consistent causal association between LDH and IS was observed by different assessment methods. The results of the inverse-variance weighted method suggested an inverse association between LDH and higher genetic predictability of IS risk (OR, 0.997; 95%CI 0.995-0.999). The weighted median estimate showed consistent results with the MR-Egger method (weighted median estimate: OR, 0.995; 95%CI 0.992-0.999; MR-Egger method: OR, 0.996; 95%CI 0.992-0.999). The inverse-variance weighted method indicates a causal association between LDH and IS (β = -0.002563, SE = 0.00128, p = .0453). MR-Egger analysis (β = -0.004498, SE = 0.001877, p = .03) and the weighted median method suggested that LDH and IS also existed causal relationship (β = -0.004861, SE = 0.001801, p = .00695).

CONCLUSIONS

Our Mendelian randomization results suggest that LDH is inversely associated with the risk of developing IS, and are contrary to the results of previous observational studies.

Association between Peripheral Arterial Lactate Levels and Malignant Brain Edema Following Endovascular Treatment for Ischemic Stroke

AIMS

To investigate the factors of postoperative malignant brain edema (MBE) in patients with acute ischemic stroke (AIS) treated with endovascular treatment (EVT).

BACKGROUND

MBE is a severe complication following EVT for AIS, and it is essential to identify risk factors early. Peripheral arterial lactate (PAL) levels may serve as a potential predictive marker for MBE.

OBJECTIVE

To determine whether immediate postoperative PAL levels and the highest PAL level within 24 hours of EVT are independently associated with MBE development in AIS patients.

METHODS

We retrospectively analyzed patients with AIS who underwent EVT from October 2019 to October 2022. Arterial blood was collected every 8 h after EVT to measure PAL, and record the immediate postoperative PAL and the highest PAL level within 24 h. Brain edema was evaluated using brain computed tomography scans within 7 days of EVT.

RESULTS

The study included 227 patients with a median age of 71 years, of whom 59.5% were male and MBE developed in 25.6% of patients (58/227). Multivariate logistic regression analysis showed that the immediate postoperative PAL (odds ratio, 1.809 [95% confidence interval (CI), 1.215-2.693]; p = 0.004) and the highest PAL level within 24 h of EVT (odds ratio, 2.259 [95% CI, 1.407-3.629]; p = 0.001) were independently associated with MBE. The area under the curve for predicting MBE based on the highest PAL level within 24 hours of EVT was 0.780 (95% CI, 0.711-0.849).

CONCLUSION

Early increase in PAL levels is an independent predictor of MBE after EVT in AIS patients.

Lactate Dehydrogenase and Hemorrhagic Stroke During Extracorporeal Membrane Oxygenation for COVID-19

PURPOSE

Hemorrhagic stroke (HS) is a devastating complication during extracorporeal membrane oxygenation (ECMO) but markers of risk stratification during COVID-19 are unknown. Lactate dehydrogenase (LDH) is a readily available biomarker of cell injury and permeability. We sought to determine whether an elevated LDH before ECMO placement is related to the occurrence of HS during ECMO for COVID-19.

METHODS

Adult patients with COVID-19 requiring ECMO between March 2020 and February 2022 were included. LDH values prior to ECMO placement were captured. Patients were categorized into high (> 750 U/L) or low (≤ 750 U/L) LDH groups. Multivariable regression modeling was used to determine the association between LDH and HS during ECMO.

RESULTS

There were 520 patients that underwent ECMO placement in 17 centers and 384 had an available LDH. Of whom, 122 (32%) had a high LDH. The overall incidence of HS was 10.9%, and patients with high LDH had a higher incidence of HS than those with low LDH level (17% vs 8%, p = 0.007). At 100 days, the probability of a HS was 40% in the high LDH group and 23% in those with a low LDH, p = 0.002. After adjustment for clinical covariates, high LDH remained associated with subsequent HS (aHR: 2.64, 95% CI 1.39-4.92). Findings were similar when restricting to patients supported by venovenous ECMO only.

CONCLUSION

Elevated LDH prior to ECMO cannulation is associated with a higher incidence of HS during device support. LDH can risk stratify cases for impending cerebral bleeding during ECMO.