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Research Report

Serum Albumin Level as a Predictor of Ischemic


Stroke Outcome
Tomasz Dziedzic, MD, PhD; Agnieszka Slowik, MD, PhD; Andrzej Szczudlik, MD, PhD

Background and PurposeAnimal studies showed that human albumin therapy is strongly neuroprotective in focal
ischemia. The aim of our study was to determine if relatively high serum albumin level is associated with decreased risk
of poor outcome in ischemic stroke patients.
MethodsSeven hundred fifty-nine consecutive patients with acute ischemic stroke were included. Functional outcome
was measured 3 months after stroke using modified Rankin Scale (mRS). Poor outcome was defined as mRS 3 or
death. Serum albumin level was measured within 36 hours after stroke onset.
ResultsPatients with poor outcome had significantly lower serum albumin level than patients with nonpoor outcome
(34.17.4 versus 36.86.7 g/L). On logistic regression analysis, serum albumin level remained independent predictor
of poor outcome (odds ratio [OR]: 0.43; 95% confidence interval [CI]: 0.26 to 0.70).
ConclusionsRelatively high serum albumin level in acute stroke patients decreases the risk of poor outcome. (Stroke.
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2004;35:e156-e158.)
Key Words: stroke cerebral ischemia outcome albumins

basis of the stroke severity on admission. SSS 25 was selected as


H uman serum albumin is a unique multifunctional protein
with neuroprotective properties. Experimental studies
showed that human albumin therapy substantially improves
a cutoff point because patients with lower scores were all nonam-
bulatory.5 Functional outcome was measured 3 months after stroke
using modified Rankin Scale (mRS).6 Poor outcome was defined as
neurological function, markedly reduces the volume of cere- mRS 3 or death.7 Nonpoor outcome was defined as mRS 4.
bral infarction, and eliminates brain swelling in animals with Serum albumin level was measured between 12 and 36 hours after
acute stroke.13 stroke onset using Roche/Hitachi analyzer. Fasting total cholesterol
We hypothesize that relatively high serum albumin level in (TC) and fibrinogen levels were measured at the same time.
acute stroke patients is associated with decreased risk of poor The study protocol was approved by the local Bioethics Commit-
tee and informed consent was obtained from all patients.
outcome.
The 2 test was used to compare proportions and Student t test was
used to compare continuous variables between groups. Logistic
Materials and Methods regression analysis was used to assess the independent contribution
Patients in this study were recruited from 818 consecutive patients of variables statistically significant on univariate analysis in the
with first-ever ischemic stroke admitted to our stroke unit between prediction of outcome. Poor outcome was coded as 1, and good
January 2000 and December 2002. Patients admitted to the hospital outcome was coded as 0. Backward logistic regression including
24 hours after stroke onset (56 patients) and patients with cancer- only variables with a P0.1 was followed by a forward logistic
ous disease or other serious diseases (3 patients) were excluded. regression including the same variables. Values of P0.05 were
Arterial hypertension was diagnosed when its presence was considered statistically significant.
documented in medical records or when at least 2 readings of blood
pressure were 140 mm Hg (systolic) or 90 mm Hg (diastolic)
after the acute phase of stroke. Ischemic heart disease was diagnosed Results
when there was a history of angina pectoris or myocardial infarction. We included 759 patients with acute ischemic stroke. Mean
Diabetes mellitus was diagnosed if its presence was documented in age was 68.312, and 372 were men. During the 3-month
medical records or patient was using insulin or an oral hypoglycemic follow-up period, 98 patients (12.9%) died.
agent. A patient was defined as a smoker if there was a history of
cigarette smoking during the past 5 years. The characteristics of patients with poor outcome and those
All patients underwent head computed tomography (CT) scan with nonpoor outcome are shown in the Table. Two hundred
within 24 hours after stroke onset. The second CT scan was sixty-six patients had poor outcome. These patients were
performed 4 to 6 days after stroke onset in 90.5% of patients. Large significantly older, more often female, and more frequently
infarcts were so designated when the sum of the largest transverse
and sagittal diameter divided by 2 was 1.5 cm.
had ischemic heart disease and atrial fibrillation. The patients
Stroke severity on admission was assessed using Scandinavian with poor outcome had significantly more severe neurologi-
Stroke Scale (SSS).4 The patients were divided into 2 groups on the cal deficit on admission measured on SSS scale and more

Received December 4, 2003; final revision received January 15, 2004; accepted February 10, 2004.
From Department of Neurology, Jagiellonian University, Krakow, Poland.
Correspondence to Dr Tomasz Dziedzic, Dept of Neurology, Jagiellonian University, Botaniczna 3, 31-503 Krakow, Poland. E-mail
dziedzictom@mediclub.pl
2004 American Heart Association, Inc.
Stroke is available at http://www.strokeaha.org DOI: 10.1161/01.STR.0000126609.18735.be

1
2 Stroke June 2004

Characteristics of Stroke Patients With Poor Outcome and Those With


Nonpoor Outcome
Patients With Patients With
Poor Outcome Nonpoor Outcome
(N266) (N493) P
Age, mean (SD) 71.9 (12.0) 65.9 (12.7) 0.01
Men, n (%) 114 (42.9) 258 (52.3) 0.01
Hypertension, n (%) 188 (70.7) 331 (67.1) 0.32
Diabetes mellitus, n (%) 57 (21.4) 106 (21.5) 0.98
Ischemic heart disease, n (%) 179 (67.3) 249 (50.5) 0.01
Atrial fibrillation, n (%) 69 (25.9) 79 (16.0) 0.01
TIA, n (%) 18 (6.8) 40 (8.1) 0.50
Smoking, n (%) 67 (25.2) 156 (31.6) 0.06
SSS score on admission, mean (SD) 19.7 (12.8) 41.5 (10.8) 0.01
Systolic blood pressure on admission 159 (31) 160 (27) 0.90
(mm Hg), mean (SD)
Diastolic blood pressure on admission 92 (18) 94 (15) 0.15
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(mm Hg), mean (SD)


Fibrinogen g/L, mean (SD) 3.3 (1.1) 3.3 (6.1) 0.90
TC mmol/L, mean (SD) 5.2 (1.4) 5.5 (1.3) 0.01
Albumin g/L, mean (SD) 34.1 (7.4) 36.8 (6.7) 0.01
TIA indicates transient ischemic attack; SD, standard deviation; SSS, Scandinavian Stroke Scale;
TC, total cholesterol.

frequently had large infarct on CT (76.9% versus 53.7%, poor outcome. On multiple logistic regression analysis, is-
P0.01). Serum albumin and TC levels were significantly lower chemic heart disease (odds ration [OR]: 1.71; 95% confi-
in patients with poor outcome than in those with nonpoor dence interval [CI]: 1.09 to 2.69), SSS score on admission
outcome. The Figure shows albumin levels versus mRS. (OR: 0.06; 95% CI: 0.04 to 0.10), infarct size (OR: 2.01; 95%
The following variables were put into logistic regression CI: 1.30 to 3.12), and serum albumin level (OR: 0.43; 95%
model: age (65 versus 65 years), sex, atrial fibrillation, CI: 0.26 to 0.70) remained independent predictors of poor
ischemic heart disease, smoking, SSS score on admission outcome. In next analysis, we put into the model the same
(25 versus 25), infarct size (large versus small), TC (6.2 variables, but age, SSS score, TC, and albumin levels were
versus 6.2 mmol/L), and serum albumin level (49 versus given as continuous variables. We found the following
49 g/L). Subjects within the upper quartile of the albumin independent predictors: age (OR: 1.03; 95% CI: 1.01 to 1.05),
distribution (49 g/L) were considered to be at lower risk for ischemic heart disease (OR: 1.73; 95% CI: 1.07 to 2.78), SSS

Serum albumin level plotted against


mRS.
Dziedzic et al Serum Albumin and Stroke Outcome 3

score on admission (OR: 0.87; 95% CI: 0.86 to 0.89), and There is no consensus on the most appropriate method and
albumin level (OR: 0.96; 95% CI: 0.93 to 0.99). timing of the stroke outcome assessment. We defined poor
When poor outcome was defined as mRS 2, logistic outcome as mRS 3 or death, because it was suggested that
regression analysis identified the following independent pre- using this cutoff point makes it easier to define poor outcome
dictors: ischemic heart disease (OR: 1.96; 95% CI: 1.27 to as opposed to favorable outcome.7 However, in the next
3.01), SSS 25 (OR: 0.06; 95% CI: 0.04 to 0.09), infarct size analysis, we used other cutoff points, also. Regardless of
(OR: 2.28; 95% CI: 1.51 to 3.43), and albumin level 49 g/L chosen cutoff point, serum albumin level remained an inde-
(OR: 0.63; 95% CI: 0.40 to 0.98). When poor outcome was pendent predictor of stroke outcome.
defined as mRS 1, we found the following independent So far, albumin therapy for stroke was assessed in only 1
predictors: ischemic heart disease (OR: 1.81; 95% CI: 1.20 to small, prospective, clinical study in which albumin was
2.72), SSS 25 (OR: 0.05; 95% CI: 0.03 to 0.09), infarct size administered in an individually customized fashion.12 The
(OR: 2.10; 95% CI: 1.43 to 3.08), and albumin level 49 g/L results of that study suggest a treatment-associated reduction
(OR: 0.58; 95% CI: 0.38 to 0.89). in mortality rate of 10%. Further studies are needed to
verify whether albumin therapy could be beneficial for acute
Discussion stroke patients.
Experimental studies of focal cerebral ischemia showed that
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Serum Albumin Level as a Predictor of Ischemic Stroke Outcome
Tomasz Dziedzic, Agnieszka Slowik and Andrzej Szczudlik

Stroke. 2004;35:e156-e158; originally published online April 8, 2004;


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doi: 10.1161/01.STR.0000126609.18735.be
Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright 2004 American Heart Association, Inc. All rights reserved.
Print ISSN: 0039-2499. Online ISSN: 1524-4628

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