Peptides 43 (2013) 133136

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Peptides
journal homepage: www.elsevier.com/locate/peptides

Prognostic value of leptin: 6-Month outcome in patients with

intracerebral hemorrhage
Xin Zhang a, , Xiao-Min Lu b , Li-Fa Huang a , Xu Li a
a
b

Department of Neurosurgery, Traditional Chinese Medical Hospital of Zhejiang Province, 54 Youdian Road, Hangzhou 310006, China
Department of Surgery, Wushan Branch, The First Hangzhou Municipal Peoples Hospital, 34 Yanguan Lane, Hangzhou 310002, China

a r t i c l e

i n f o

Article history:
Received 27 February 2013
Received in revised form 11 March 2013
Accepted 11 March 2013
Available online 18 March 2013
Keywords:
Leptin
Intracerebral hemorrhage
6-Month clinical outcome

a b s t r a c t
Leptin has recently been discussed as a novel biomarker for the clinical outcome of critical illness. This
study aims to investigate the prognostic value of leptin with regard to long-term clinical outcomes in
patients with intracerebral hemorrhage. In 50 healthy controls and 92 patients with acute spontaneous
basal ganglia hemorrhage presenting to the emergency department of a large primary care hospital,
we measured plasma leptin levels using an enzyme-linked immunosorbent assay in a blinded fashion.
Plasma leptin levels on admission were considerably higher in patients than healthy controls. A signicant correlation emerged between plasma leptin level and National Institutes of Health Stroke Scale
score. A multivariate analysis identied plasma leptin level as an independent predictor for 6-month clinical outcomes including 6-month mortality and unfavorable outcome (Modied Rankin Scale score > 2).
Using receiver operating characteristic curves, we calculated areas under the curve for 6-month clinical outcomes. The predictive performance of leptin was similar to, but did not obviously improve that
of National Institutes of Health Stroke Scale scores. Thus, leptin may help in the prediction of 6-month
mortality and unfavorable outcome after intracerebral hemorrhage.
2013 Elsevier Inc. All rights reserved.

1. Introduction

2. Materials and methods

Leptin, the 16,000 Da protein product of the obesity gene (ob), is

principally derived from white adipose tissue, and not only acts on
the central nervous system to reduce appetite and increase energy
expenditure, but also plays crucial roles in regulating inammation and immune [1,4,8,9,1315]. Present investigations on animals
have found that brain cortex leptin mRNA expression and serum
leptin level are up-regulated in mouse with ischemic brain injury
and in rat with traumatic brain injury [2,6,18]. Moreover, leptin levels in peripheral blood are highly associated with cerebral
hemorrhagic or ischemic stroke [16,17], and independently predict in-hospital and 1-week mortality of patients with intracerebral
hemorrhage (ICH) and 6-month clinical outcome of pediatric traumatic brain injury [7,11,19]. This follow-up study further evaluated
leptin as a marker to predict long-term functional outcome and
mortality at 6 months after admission in acute ICH patients.

2.1. Study population

Institution at which the work was performed: Traditional Chinese Medical Hospital
of Zhejiang Province.
Corresponding author. Tel.: +86 0571 87068001.
E-mail address: changzhouzhangxin@163.com (X. Zhang).
0196-9781/$ see front matter 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.peptides.2013.03.010

This prospective study was conducted during the period of

January 2010March 2012 by the Department of Neurosurgery,
Traditional Chinese Medical Hospital of Zhejiang Province. The
consecutive patients with acute spontaneous basal ganglia hemorrhage were evaluated within 6 h from symptoms onset at the
emergency room. Exclusion criteria included existing previous neurological disease, head trauma, use of antiplatelet or anticoagulant
medication, presence of other prior systemic diseases including
uremia, liver cirrhosis, malignancy, and chronic heart or lung disease, with the exceptions of diabetes mellitus and hypertension.
The patients who underwent a surgical procedure and had missing of follow-up or unavailable leptin measurements were also
excluded. Healthy individuals were evaluated as controls if they
presented to our hospital and had blood collected as part of medical
examination on March 2012. The study was conducted in accordance with the guidelines approved by the Human Research Ethics
Committee at Traditional Chinese Medical Hospital of Zhejiang
Province. Written informed consent was obtained from the study
subjects or their relatives.

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X. Zhang et al. / Peptides 43 (2013) 133136

2.2. Clinical and radiological assessment

The level of neurological status on admission was assessed by
National Institutes of Health Stroke Scale (NIHSS) scores. Early neurological deterioration was dened as the increase of 4 points in
the NIHSS score at 24 h from symptoms onset. At 6 months after
ICH, the patients that scored >2 on the modied Rankin Scale were
considered as having an unfavorable outcome.
All computerized tomography scans were performed according
to the neuroradiology department protocol. Investigators who read
them were blinded to clinical information. Patients underwent an
initial CT scan on admission and a follow-up CT scan at 24 h from
symptoms onset. Hematoma volume was measured according to
the previously reported formula A B C 0.5 [10]. Hematoma
growth was dened as an increase of >33% in the volume of intraparenchymal hemorrhage as measure by CT compared with the
initial scan [5].
Fig. 1. Graph showing receiver operating characteristic curve analysis of plasma
leptin level for 6-month mortality.

2.3. Immunoassay methods

The informed consents were obtained from study population
or family members in all cases before the blood were collected.
Venous blood in the healthy individuals or the ICH patients was
drawn at study entry or on admission. The blood samples were
immediately placed into sterile EDTA test tubes and centrifuged
at 3000g for 30 min at 4 C to collect plasma. Plasma was stored
at 70 C until assayed. The concentration of leptin in plasma was
analyzed by enzyme-linked immunosorbent assay using commercial kits (R&D Systems, Minneapolis, MN, USA) in accordance with
the manufactures instructions. The person carrying out the assays
was completely blinded to the clinical information.
2.4. Statistical analysis
Statistical analysis was done using the SPSS 12.0 statistical
package (SPSS Inc., Chicago, IL, USA) and MedCalc 9.6.4.0. (MedCalc Software, Mariakerke, Belgium). All values are expressed as
mean standard deviation or counts (percentage) unless otherwise
specied. Signicance for intergroup differences was assessed by
chi-square test or Fisher exact test for categorical variables and
MannWhitney U test for continuous variables. Receiver operating characteristics (ROC) curves were congured to establish the
cut-off points of leptin with the optimal sensitivity and specicity
predicting 6-month clinical outcomes. Finally, 2 logistic regression analyses were performed to determine the factors that could
be considered as independent predictors of 6-month clinical outcomes, using the forward stepwise method. Variables showing a
P < 0.1 in univariate analysis were included in the multivariate
model. In a combined logistic-regression model, we estimated the
additive benet of leptin to NIHSS score. A P value < 0.05 was considered signicant.

3. Results

P < 0.001) as well as between plasma leptin level and plasma Creactive protein level (r = 0.542, P < 0.001).
3.2. Impact of leptin on 6-month mortality
Thirty-four patients (37.0%) died from ICH at 6 months. Higher
baseline plasma leptin level was associated with 6-month mortality, as well as other variables shown in Table 1. A multivariate
analyses selected NIHSS score (odds ratio (OR), 1.221; 95% condence interval (CI), 1.1291.804; P < 0.001) and baseline plasma
leptin level (OR, 1.216; 95% CI, 1.1242.501; P < 0.001) as the independent predictors for 6-month mortality. A ROC curve showed
that the plasma leptin level predicted 6-month mortality of patients
with high area under curve (AUC) (Fig. 1). The predictive value
of the leptin concentration was thus similar to that of NIHSS
score (AUC, 0.850; 95% CI, 0.7610.916) (P = 0.586). In a combined
logistic-regression model, leptin improved the AUC of NIHSS score
to 0.880 (95% CI, 0.7960.939) but the difference was not signicant
(P = 0.228).
3.3. Impact of leptin on 6-month unfavorable outcome
Fifty-one patients (55.4%) suffered from unfavorable outcome at
6 months. Higher baseline plasma leptin level was associated with
6-month unfavorable outcome, as well as other variables shown in
Table 1. A multivariate analyses selected NIHSS score (OR, 1.304;
95% CI, 1.1421.917; P < 0.001) and baseline plasma leptin level (OR,
1.284; 95% CI, 1.1412.760; P < 0.001) as the independent predictors for 6-month unfavorable outcome. A ROC curve showed that
the plasma leptin level predicted 6-month unfavorable outcome of
patients with high AUC (Fig. 2). The predictive value of the leptin
concentration was thus similar to that of NIHSS score (AUC, 0.882;
95% CI, 0.7980.940) (P = 0.329). In a combined logistic-regression
model, leptin improved the AUC of NIHSS score to 0.920 (95% CI,
0.8450.966) but the difference was not signicant (P = 0.067).

3.1. Study populations characteristics

4. Discussion
Finally, 92 ICH patients and 50 healthy controls were enrolled
in this study. The intergroup differences in age, gender and body
mass index were not statistically signicant (all P > 0.05). The demographic, clinical and laboratory data of patients were provided in
Table 1. The admission leptin levels were signicantly increased
in all patients (19.1 7.7 ng/mL) compared with healthy control
individuals (7.9 3.3 ng/mL, P < 0.001). A signicant correlation
emerged between plasma leptin level and NIHSS score (r = 0.561,

Recent two studies have demonstrated that leptin levels in

peripheral blood independently predict in-hospital and 1-week
mortality of the patients with ICH [7,19]. To the best of our knowledge, this study is among few studies that analyzed the association
of plasma leptin level with long-term clinical outcomes in ICH.
This study demonstrated that the plasma leptin levels on admission is considerably increased and markedly predicts 6-month

X. Zhang et al. / Peptides 43 (2013) 133136

135

Table 1
Patients characteristics and the factors associated with 6-month clinical outcomes.
Characteristics

Gender (male/female)
Age (years)
Body mass index (kg/m2 )
Hypertension
Diabetes mellitus
NIHSS score
Hematoma volume (mL)
Presence of intraventricular hemorrhage
Hemorrhage growth
Early neurological deterioration
Admission time (h)
Plasma-sampling time (h)
Systolic arterial pressure (mm Hg)
Diastolic arterial pressure (mm Hg)
Blood glucose level (mmol/L)
Plasma C-reactive protein level (mg/L)
Plasma D-dimer level (mg/L)
Plasma leptin level (ng/mL)

Overall (n = 92)

54/38
64.6 10.7
25.5 2.2
81 (88.0%)
22 (23.9%)
19.0 5.3
31.6 18.4
38 (41.3%)
15 (16.3%)
22 (23.9%)
2.2 1.3
4.6 2.4
171.9 26.2
92.5 12.5
12.4 4.5
8.8 3.4
2.4 1.0
19.1 7.7

6-Month mortality

6-Month functional outcome

Survival group
(n = 58)

Non-survival
group (n = 34)

Univariate
analysis P
values

Favorable
outcome
(n = 41)

Unfavorable
outcome
(n = 51)

Univariate
analysis P
values

34/24
62.5 10.9
25.3 2.3
49 (84.5%)
9 (15.5%)
16.7 5.0
23.8 15.2
16 (27.6%)
6 (10.3%)
8 (13.8%)
2.2 1.3
4.9 2.6
170.1 27.4
91.9 13.7
11.3 3.3
8.0 3.0
2.2 1.0
16.1 7.4

20/14
68.4 9.6
25.9 1.9
32 (94.1%)
13 (38.2%)
22.9 3.3
44.9 15.7
22 (64.7%)
9 (26.5%)
14 (41.2%)
2.1 1.2
4.1 2.2
174.9 24.1
93.6 10.0
14.4 5.5
10.2 3.8
2.7 0.9
24.3 5.1

0.985
0.010
0.225
0.169
0.014
<0.001
<0.001
<0.001
0.043
0.003
0.584
0.144
0.396
0.481
0.004
0.004
0.014
<0.001

25/16
62.0 10.3
25.1 2.4
35 (85.4%)
5 (12.2%)
15.2 4.7
22.4 15.0
8 (19.5%)
3(7.3%)
5 (12.2%)
2.4 1.4
5.0 2.7
175.2 26.8
93.7 14.2
11.0 3.4
7.6 2.6
2.0 0.9
14.1 6.8

29/22
66.7 10.9
25.9 2.0
46 (90.2%)
17 (33.3%)
22.0 3.5
39.0 17.6
30 (58.8%)
12 (23.5%)
17 (33.3%)
2.0 1.2
4.3 2.2
169.2 25.7
91.6 10.9
13.6 5.0
9.8 3.7
2.7 1.0
23.2 5.7

0.690
0.036
0.107
0.478
0.018
<0.001
<0.001
<0.001
0.036
0.018
0.158
0.162
0.281
0.427
0.004
0.002
0.001
<0.001

Numerical variables were presented as mean standard deviation. Categorical variables were expressed as counts (percentage). Numerical variables were analyzed by
MannWhitney U-test. Categorical variables were analyzed by chi-square test or Fisher exact test.

clinical outcomes. Importantly, the prognostic value of leptin is

similar to that of the NIHSS score, substantiating its potential as
a new prognostic biomarker.
Leptin is a 146 amino acid protein with a molecular weight
of 16 kDa encoded by the ob gene and primarily, but not exclusively, is expressed by the white adipose tissue and is implicated
in obesity, food intake, and energy homeostasis [1,9]. Several activating effects toward T cells, monocytes, endothelium cells and
cytokine production have been reported and might suggest a
pro-inammatory role for leptin in the setting of acute systemic
inammation [4,8,1315]. Leptin enters the brain via saturable
transport across the bloodbrain barrier [3]. Leptin mRNA is selectively transcribed in specic areas of the brain and pituitary in rat,
pig, sheep and human [12]. Brain cortex leptin mRNA expression
and serum leptin level are up-regulated in mouse with ischemic
brain injury and in rat with traumatic brain injury [2,6,18]. These
observations imply that the enhancement of leptin level in the
peripheral blood of patients with ischemic or hemorrhagic stroke
and pediatric traumatic brain injury could be a general response in
the pathology of brain damage [7,11,16,17,19]. In agreement with

recent report [7], this study also found that plasma leptin level
is related to plasma C-reactive protein level in ICH. Theses ndings suggest leptin may contribute to the inammatory process of
hemorrhagic brain injury.
In addition, our data suggested that plasma leptin level might
reect the severity of ICH (as demonstrated by the close relation
between leptin and the NIHSS score). Leptin independently predicted 6-month mortality and unfavorable outcome in this group
of ICH patients and its discriminative power (reected by AUC) was
in the range of the NIHSS score which is known to be a strong
individual outcome predictor. However, leptin did not statistically
signicantly improve the AUC of the NIHSS score. Therefore, the
detection of plasma leptin concentration can be useful for the clinical management of ICH.
5. Conclusions
This study suggests that higher plasma leptin level correlates
with disease severity and markers of system inammation and represents a novel biomarker for predicting 6-month clinical outcomes
in patients with ICH.
Competing interests
The authors declare that they have no competing interests.
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Fig. 2. Graph showing receiver operating characteristic curve analysis of plasma

leptin level for 6-month unfavorable outcome.

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