American Journal of Emergency Medicine 34 (2016) 1812–1816

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American Journal of Emergency Medicine

journal homepage: www.elsevier.com/locate/ajem

Original Contribution

Serum albumin level is associated with the recurrence of acute

ischemic stroke
Qing Zhang, MD, Ma (Master of Medicine) a, Yi-Xiong Lei, MD, PhD b, Qiang Wang, MD, PhD a, Yong-Ping Jin, MD a,
Rong-Li Fu c, He-Hong Geng, MD, Ma (Master of Medicine) a, Ling-Ling Huang, MD, Ma (Master of Medicine) a,
Xiao-Xiao Wang, MD, Ma (Master of Medicine) a, Pei-Xi Wang, MD, PhD a,b,⁎
a
Institute of Public Health, School of Nursing, Henan University, Kaifeng, 475004, China
b
Department of Preventive Medicine, School of Public Health, Guangzhou Medical University, Guangzhou, 510180, China
c
Internal Medicine-Neurology, Huaihe Hospital, Henan University, Kaifeng, 475000, China

a r t i c l e i n f o a b s t r a c t

Article history: Background: Previous studies have confirmed that low serum albumin levels in acute ischemic stroke patients
Received 9 June 2016 increased the risk for poor outcome and death, demonstrating the neuroprotective role of albumin. However,
Accepted 9 June 2016 there are few studies investigating the relationship between albumin levels and recurrence of stroke. The aim
of this study was to evaluate the effect of serum albumin level on the risk of recurrence in patients with acute
ischemic stroke.
Methods: Seven hundred fifty-three consecutive patients with acute first-ever ischemic stroke were recruited in
this study. Recurrent outcome was measured 1 year after stroke through home interviews (n = 692).
Results: Patients with recurrence had significantly lower serum albumin level than those without recurrence
(37.07 ± 4.21 vs 38.91 ± 3.25). The multiple logistic regression adjustment for confounding factors showed
that the association remained significant for patients in the second albumin quartile, the third quartile, and the
fourth quartile compared with patients in the first quartile (adjusted odds ratio [aOR] = 0.543, 95% confidence
interval [CI]: 0.307-0.959, P= .036; aOR = 0.449, 95% CI: 0.249-0.812, P= .008; and aOR = 0.290, 95% CI:
0.148-0.570, P b .001).
Conclusion: Lower serum albumin level increases the risk of recurrence in patients with acute ischemic stroke,
suggesting that serum albumin level might be used as an indicator for stroke recurrence.
© 2016 Elsevier Inc. All rights reserved.

1. Introduction such as myocardial infarction and cardiovascular diseases [7–9].

Stroke has been ranked as the leading causes of death and long-term
disability in China and many other countries [1]. With the development
of medicine and rehabilitation medicine, the situation of handicap de-
gree and mortality has been ameliorated. However, increased recur-
rence of stroke has been observed in recent years, leading to doubled
rate of disability and death. Surprisingly, traditional vascular risk factors,
such as age, hypertension, diabetes, dyslipidemia, and smoking, cannot
fully account for the recurrence of stroke.
Serum albumin is a unique multifunctional protein and has been
shown to be neuroprotective [2–6]. Several studies have demonstrated
the obvious protective influence of serum albumin in many diseases,
In recent years, some studies have showed a neuroprotective effect of
serum albumin in ischemic stroke on animal models.
Some reports have also suggested that relatively low serum albumin
levels in acute ischemic stroke patients increased the risk for poor out-
come [10] or death [11]. However, there are few studies investigating
the relationship between albumin levels and recurrence of stroke.
Therefore, the objective of this prospective cohort study with a follow-
up period of 12 months was to evaluate the association between albu-
min level and stroke recurrence.
2. Methods

⁎ Corresponding author at: Institute of Public Health, School of Nursing, Henan Univer-
sity, Kaifeng, China.
E-mail addresses: zq71200@163.com (Q. Zhang), gz-leizeng@163.com (Y.-X. Lei),
kfwq@henu.edu.cn (Q. Wang), jinyongping@henu.edu.cn (Y.-P. Jin),
15225475536@163.com (R.-L. Fu), 15226003150@163.com (H.-H. Geng),
huanglingling0703@163.com (L.-L. Huang), xiaoxiao52625@163.com (X.-X. Wang),
peixi001@163.com (P.-X. Wang).
2.1. Patients
This prospective cohort study included 753 first-ever ischemic
stroke patients during acute phase (the first week following a stroke)
with a 1-year follow-up. All patients admitted into the neurological de-
partment at Huai-He Hospital in Kaifeng, China, from March 2014 to
March 2015 were evaluated for eligibility for the study. Informed

http://dx.doi.org/10.1016/j.ajem.2016.06.049
0735-6757/© 2016 Elsevier Inc. All rights reserved.
 Q. Zhang et al. / American Journal of Emergency Medicine 34 (2016) 1812–1816
All ischemic Stroke respondents N = 1832
Acute phase ( 7 day) N = 1141
First-ever stroke N = 851
Without TIA N = 783
Final study sample N = 769
First study sample N = 753
With follow-up N = 692
Patients followed up with and without
recurrent N = 684
Fig. 1. Flowchart in the selection of study patients.
consent was obtained from all patients before this study. This study
complies with the Declaration of Helsinki and was approved by the eth-
ical committee of Henan University. All patients were examined for is-
chemic stroke, which was confirmed by computed tomographic scan
and magnetic resonance imaging according to the fourth Chinese Na-
tional Conference's recommendations on the diagnosis of cerebrovascu-
lar diseases [12]. Patients with major cardiac, renal, hepatic, and
endocrinological disorders; skeletal disorders; malignant tumor; recent
surgery; and recent infections were excluded. A flowchart illustrating
the selection of patients is presented in Fig. 1. Six hundred ninety-two
cases were included in this study after excluding 61 cases that were
lost to follow-up.
2.2. Baseline survey
Sociodemographic variables included age, sex, marital status, and
living arrangement. Lifestyle factors included smoking, alcohol drinking,
family history, hypertension history, diabetes history, coronary heart
disease history, hyperlipidemia, and body mass index (BMI). Hyperten-
sion was diagnosed as systolic blood pressure N140 mm Hg and/or dia-
stolic blood pressure N 90 mm Hg based on the average of the 2 blood
pressure measurements, or patient's self-reported history of hyperten-
sion or antihypertensive use, supported by the Joint National Commit-
tee VI-VII. Diabetes was diagnosed if the fasting plasma glucose was
N110 mg/dL or if patient was on antidiabetic medications. Smokers
were defined as those smoking 1 or more cigarettes per day for 1 year
or those with smoking cessation b5 years [13]. Alcohol drinking was de-
fined as consumption of at least 1 alcoholic drink in a week and more
years. A positive family history was defined as history of ischemic stroke
in a first-degree relatives. Hyperlipidemia was diagnosed as elevated
plasma level in at least one of total cholesterol, triglyceride, high-
density lipoprotein, and low-density lipoprotein. Weight and height of
patients were measured on admission. BMI was categorized according
to Chinese weight criteria [14].
2.3. Blood sample collection
Blood samples for assessment of albumin were obtained from all
patients within 24 hours of admission after stroke onset. Concentrations
1813
Non Acute phase ( 7 day) N = 691
Previous stroke N = 290
With transient ischemic attack
(TIA) N = 68
With severe dysfunction N = 14
Date uncompleted N = 16
Lost follow-up N = 61
Died without recurrent stoke N = 8
of albumin and other laboratory examinations (total cholesterol,
triglyceride, high-density lipoprotein, low-density lipoprotein) were
determined using the full automatic biochemical analyzer (Germany,
SIEMENS ADVIA2400). Hypoproteinemia was diagnosed if the levels of
albumin were b 35 g/L.
2.4. Follow-up
Follow-up assessment was conducted in all patients by well-trained
home interviewers at 1 year after hospital discharge. The information
included recurrence, time of recurrent stroke, type of recurrence,
survival status, and cause of death.
2.5. Statistical analysis
All statistical analyses were conducted with SPSS 17.0 (SPSS, Inc,
Chicago, IL). Categorical variables are reported as frequency and per-
centage, and continuous variables are presented as median values or
means ± standard deviations (SDs). The associations between albumin
level and baseline demographic variables or cerebrovascular risk factors
were examined using χ2 test for categorical variables. For the compari-
sons between groups, χ 2 and Student t test or 1-way analysis of
variance were conducted for categorical and continuous variables, re-
spectively. In the multivariate analyses, we used the forward selection
procedure to adjust for potential clinically relevant confounders, includ-
ing age, sex, marital status, residence, smoking, alcohol drinking, family
history, hypertension, diabetes, coronary heart disease, hyperlipidemia,
and BMI. Statistical significance was defined as a P value b .05.
3. Results
3.1. Patients' characteristics
A total of 753 ischemic stroke patients were enrolled in the study,
and the characteristics of all patients, including follow-up group and
lost to follow-up group, are presented in Table 1. There was no signifi-
cant difference between follow-up group and lost to follow-up group.
Six hundred ninety-two patients (91.9%) completed the first year of
follow-up with the mean of age being 64 years (SD = 12.8). The mean
1814 Q. Zhang et al. / American Journal of Emergency Medicine 34 (2016) 1812–1816

Table 1 Table 3
Sociodemographic and clinical characteristics of all patients with follow-up vs those lost to Adjusted odds ratio for the associations between risk factors and hypoalbuminemia of is-
follow-up chemic stroke

Sociodemographic variables Lost to follow-up Follow-up P value Variable aOR 95% CI P value
n = 61 n = 692
Age (y)
Age (y) .584 b60 Reference
b60 21 (7.3) 266 (92.7) ≥60 3.231 1.805-5.786 b.001
≥60 40 (8.6) 426 (91.4) BMI
Sex .789 Normal weight Reference
Male 34 (7.9) 398 (92.1) Underweight 3.970 1.408-11.199 .009
Female 27 (8.4) 294 (91.6) Overweight 0.599 0.367-0.976 .040
Marital status Obese 0.359 0.164-0.788 .011
Single 14 (12.3) 100 (87.7) .092
Married 47 (7.4) 592 (92.6)
Residence .593
Urban 31 (7.6) 379 (92.4) 3.2. Follow-up investigation
Rural 30 (8.7) 313 (91.3)
Hypertension, n (%) 34 (8.4) 372 (91.6) .790 During 1 year after hospital discharge, 22 (3.2%) patients died, with
Diabetes, n (%) 18 (10.6) 152 (89.4) .201
14 patients dead from the recurrence of ischemic stroke and 8 patients
Coronary heart disease, n (%) 11 (11.3) 86 (88.7) .230
Hyperlipidemia, n (%) 41 (8.5) 440 (91.5) .677 dead from other diseases. Ninety-seven (14.0%) patients had recurrent
Family history, n (%) 10 (8.5) 108 (91.5) .855 ischemic stroke. Detailed results for these patients are shown in
Smoking, n (%) 20 (9.5) 190 (90.5) .374 Table 4. Fig. 2 shows the univariate association between albumin
Alcohol drinking, n (%) 16 (9.4) 155 (90.6) .524 quartiles and outcome events (recurrence and death). The recurrence
BMI .201
and mortality rates were significantly higher in patients in the first
Underweight 3 (17.6) 14 (82.4)
Normal weight 24 (8.4) 261 (91.6) (lowest) albumin quartile than those in patients in the fourth (highest)
Overweight 28 (8.8) 290 (91.2) quartile (Pb .05).
Obese 6 (4.5) 127 (95.5) The characteristics of patients with recurrence of ischemic stroke
and those without recurrence of ischemic stroke are shown in Table 5.
The prevalence of recurrence was decreased with increased albumin
albumin level of all patients was 38.6 (range, 21.16-47.30) g/L. The char- levels, and the first (lowest) albumin quartile patients had the highest
acteristics of patients, stratified according to albumin quartiles, were prevalence of stroke recurrence. In addition, hypoproteinemia was asso-
shown in Table 2. Patients with lower albumin level were more likely ciated with increased prevalence of stroke recurrence (Pb .001).
to be older; be single; live in rural areas; and have hypertension, coro- After adjustment for a number of independent predictors, the inde-
nary heart disease, and hyperlipidemia than patients with elevated al- pendent association between recurrent stroke and albumin level as
bumin level. The association of risk factors, such as age (60 years as assessed by multivariate logistic regression analysis is shown in
the cutoff value) and BMI, with hypoalbuminemia was observed in pa- Table 6. After adjustment for confounders, the association remained sig-
tients as assessed by multivariate logistic regression analysis (Table 3). nificant for patients in the second albumin quartile, the third quartile,
and the fourth quartile compared with patients in the first quartile
(adjusted odds ratio [aOR] = 0.543, 95% confidence interval [CI]:
0.307-0.959, P= .036; aOR = 0.449, 95% CI: 0.249-0.812, P= .008; and
aOR = 0.290, 95% CI: 0.148-0.570, P b .001). With increased albumin
Table 2
levels, the risk of recurrent stroke was significantly lower. In addition,
Characteristics of all patients according to quartiles of albumin levels being single (aOR = 1.785, 95% CI: 1.002-3.119, P= .042) and having di-
abetes (aOR = 2.120, 95% CI: 1.310-3.431, P= .002) were significantly
Variables Quartile of plasma albumin level, g/L P
associated with higher risk of recurrent stroke.
value
Q1 Q2 Q3 Q4 The patients with hypoproteinemia had more than 3 times
(≦36.7) (36.7-38.8) (38.8-40.8) (N40.8)
the chance to suffer from recurrence (aOR = 3.261, 95% CI: 1.914-
n = 183 n = 170 n = 170 n = 169
5.555, P b .001) after adjustment for other indicators. Moreover, being
Age (y) b.001 single (aOR = 1.912, 95% CI: 1.093-3.343, P= .023) and having diabetes
b60 37 (13.9) 64 (24.1) 74 (27.8) 90 (34.2)
≥60 146 (34.3) 106 (24.9) 96 (22.5) 78 (18.3)
(aOR = 2.098, 95% CI: 1.295-3.398, P= .003) were significantly associ-
Sex .228 ated with higher risk of recurrent stroke.
Male 95 (23.9) 102 (25.6) 96 (24.1) 105 (26.4)
Female 88 (29.9) 68 (23.1) 74 (25.2) 64 (21.8) 4. Discussion
Marital status .022
Single 38 (38.0) 24 (24.0) 22 (22.0) 16 (16.0)
Married 145 (24.5) 146 (24.7) 148 (25.0) 153 (25.8) We found that hypoalbuminemia was associated with ischemic
Residence .012 stroke recurrence and that patients with hypoalbuminemia had 3.261-
Urban 94 (24.8) 80 (21.1) 97 (25.6) 108 (28.5) fold increased risk of recurrence 1 year after stroke. Besides, patients
Rural 89 (28.4) 90 (28.8) 73 (23.3) 61 (19.5)
Hypertension, n (%) 88 (23.7) 93 (25.0) 83 (22.3) 108 (29.0) .011
Diabetes, n (%) 35 (23.0) 37 (24.3) 42 (27.6) 38 (25.0) .651 Table 4
Coronary heart disease, n (%) 32 (37.2) 19 (22.1) 24 (27.9) 11 (12.8) .015 Follow-up outcome of 692 patients
Hyperlipidemia, n (%) 103 (23.4) 112 (25.5) 102 (23.2) 123 (28.0) .008
Classification Number (n = 692) Proportion (%)
Family history, n (%) 27 (24.8) 24 (22.0) 23 (21.1) 35 (32.1) .236
Smoking, n (%) 46 (24.2) 42 (22.1) 50 (26.3) 52 (27.4) .494 Recurrence
Alcohol drinking, n (%) 31 (20.0) 34 (21.9) 42 (27.1) 48 (31.0) .052 Recurrence 97 15.2
BMI b.001 No recurrence 595 84.8
Underweight 9 (64.3) 0 (0.0) 4 (28.6) 1 (7.1) Death
Normal weight 106 (40.6) 66 (25.3) 50 (19.2) 39 (14.9) Death with recurrence 14 2.0
Overweight 50 (17.2) 72 (24.8) 87 (30.0) 81 (27.9) Death without recurrence 8 1.2
Obese 18 (14.2) 32 (25.2) 29 (22.8) 48 (37.8) No death 670 96.8
 Q. Zhang et al. / American Journal of Emergency Medicine 34 (2016) 1812–1816 1815

[15,16]. Patients with hypoalbuminemia had increased mortality rate

6 months after the first onset of stroke [11]. However, no long-term
follow-up studies have demonstrated the relationship between low al-
bumin level and mortality.
In our study, the recurrence of acute first-ever ischemic stroke at 1
year was 14.0%, consistent with the findings as demonstrated in previ-
ous studies [17]. Low albumin level has been shown to be capable to
predict the severity of ischemic stroke for follow-up at 30 days [18]
and 3 months [10]. Several studies in different populations found that
serum albumin level had a negative correlation with stroke severity
[8,11]. To the best of our knowledge, few researchers have investigated
the correlation of albumin level with stroke recurrence. Our study for
the first time found that the serum albumin level on admission was
closely related to the recurrence of ischemic stroke during acute phase
Fig. 2. Association between albumin and follow-up outcomes. Note: **Pb .001; *Pb .05. Re- and that albumin level was negatively correlated with the rate of stroke
currence (a): excluding 8 dead cases without recurrence.
recurrence in 1 year.
Apart from low level of albumin, our study found that marriage and
in the first quartile of albumin level were more likely to suffer from re- diabetes were also associated significantly with the recurrence of ische-
current stroke and death. The risk of recurrence decreased, respectively, mic stroke after controlling all other confounding risk factors in a step-
to be 45.7%, 55.1%, and 71.0% for the second quartile, the third quartile, wise multiple logistic regression analysis, consistent with the close
and the fourth quartile of albumin level in patients after adjustment for association of diabetes with the recurrence of ischemic stroke [19]. Dia-
age, sex, marital status, residence, smoking, alcohol drinking, family his- betes might increase the risk of recurrent stroke through endogenous
tory, hypertension, diabetes, coronary heart disease, hyperlipidemia, cardiovascular. NO system [20] as supported by the fact that hypergly-
and BMI. Hypoalbuminemia or low albumin level on admission cemia may destroy the blood-brain barrier and enhance hemorrhagic
was an independent predictor for 1-year recurrence rate of acute infarct conversion [21]. However, the exact molecular mechanism of
ischemic stroke. The recurrence rate of stroke increases with decreased how diabetes affects ischemic stroke recurrence is unclear and requires
albumin level. further investigation.
Multivariate logistic regression analysis of the relationship between Serum albumin often has been identified as a nutrition marker relat-
albumin level and mortality was not performed because of small num- ed to nutrition status and inflammation [22]. Previous studies [23,24]
bers of death in our study. However, some previous studies had con- had showed that plasma protein synthesis was inhibited in malnutrition
firmed that albumin level is closely related to mortality in stroke. patients. The acute phase proteins can protect the body from trauma, in-
Some researchers demonstrated that hypoalbuminemia is an indepen- fection, and tissue damage. As demonstrated in this present study, age
dent predictor for in-hospital mortality in patients with acute stroke and BMI were strongly correlated with hypoalbuminemia after adjust-
ment of other variables, and a higher prevalence rate of hypoalbumin-
emia was associated with lower BMI. The elderly and lower-BMI
Table 5 patients were more vulnerable to malnutrition, which may be partial
Characteristics between recurrence and no-recurrence groups of ischemic stroke explanations for the effect of age and BMI on hypoalbuminemia, further
Variables Recurrence No recurrence P value supported by a previous study demonstrating that patients with malnu-
N = 97 N = 587 trition before ischemic stroke had worse neurological function after ill-
Age (y) .434 ness [25].
b60 34 (12.8) 231 (87.2) Albumin serves the transport of hormones, drugs, amino acids, and
≥60 63 (15.0) 356 (85.0) free fatty acids in the blood as a vehicle and can modulate the colloid os-
Sex .825
motic pressure in blood [26]. Serum albumin [3] plays a neuroprotective
Male 55 (13.9) 340 (86.1)
Female 41 (14.5) 248 (85.5)
Marital status .025
Single 21 (22.1) 74 (77.9) Table 6
Married 76 (12.9) 513 (87.1) Adjusted odds ratio for the associations between risk factors and recurrence of ischemic
Residence .660 stroke
Urban 51 (13.6) 325 (86.4)
Variable aOR 95% CI P value
Rural 46 (14.9) 262 (85.1)
Hypertension, n (%) 54 (14.6) 316 (85.4) .743 Recurrence
Diabetes, n (%) 32 (21.2) 119 (78.8) .008 Marital status a, b
Coronary disease, n (%) 15 (18.3) 67 (81.7) .242 Married Reference
Hyperlipidemia, n (%) 58 (13.3) 377 (86.7) .426 Single 1.785 a; 1.002-3.119 a;1.093-3.343 b .042a;
Family history, n (%) 16 (15.0) 91 (85.0) .765 1.912 b .023b
Smoking, n (%) 25 (13.4) 162 (86.6) .806 Diabetes a, b
Alcohol drinking, n (%) 21 (13.6) 133 (86.4) .896 No Reference
BMI .252 Yes 2.120 a; 1.310-3.431 a; .002a;
Underweight 4 (28.6) 10 (71.4) 2.098 b 1.295-3.398 b .003b
Normal weight 41 (16.0) 215 (84.0) Albumin, quartiles a
Overweight 35 (12.2) 252 (87.8) Q1 (≦36.7) Reference
Obese 17 (13.4) 110 (86.6) Q2 (36.7-38.8) 0.543 0.307-0.959 .036
Albumin, mean (SD) 37.07 ± 4.21 38.91 ± 3.25 b.001 Q3: (38.8-40.8) 0.449 0.249-0.812 .008
Albumin, quartiles, n (%) b.001 Q4: (﹥40.8) 0.290 0.148-0.570 b.001
Q1 (≦36.7) 41 (22.8) 139 (77.2) Hypoalbuminemia b 3.261 1.914-5.555 b.001
Q2 (36.7-38.8) 23 (13.7) 145 (86.3)
Model a: Albumin quartiles (Q1, Q2, Q3, Q4) related to other risk factors (age, sex, marital
Q3 (38.8-40.8) 21 (12.4) 149 (87.6)
status, residence, smoking, alcohol drinking, family history, hypertension, diabetes, coro-
Q4 (N40.8) 12 (7.2) 154 (92.8)
nary heart disease, hyperlipidemia, BMI) from multivariate logistic regression models.
Hypoalbuminemia, n (%) 26 (30.2) 60 (69.8) b.001
Model b: Hypoalbuminemia related to other risk factors from multivariate logistic regres-
Recurrence: Excluded 8 dead cases without recurrence. sion. Recurrence : Excluded 8 dead cases without recurrence.
1816 Q. Zhang et al. / American Journal of Emergency Medicine 34 (2016) 1812–1816
role in ischemic stroke through a variety of mechanisms, such as im-
proving blood flow perfusion of brain [4], enhancing micrangium perfu-
sion [27], reducing the various cytokines’ adhesion within postcapillary
microcirculation [28], and increasing the transport of free fatty acids
postischemia [29]. In addition, albumin also has been reported to reduce
the hematocrit value, block the erythrocyte aggregation, and decrease the
erythrocyte sedimentation rate [4,30,31]. Serum albumin is conducive to sus-
taining neuronal metabolism by increasing the export of pyruvate to neurons
after entering the brain under pathologic conditions [8].
Belayev et al [32] found that delayed high-concentration albumin
therapy initiated 2 to 4 hours after stroke onset of transient focal ische-
mia in rats had beneficial effects. A previous study showed that
moderate-dose human albumin therapy observably improves neuro-
logic function and reduces infarction volume and brain swelling in ani-
mals with acute focal ischemic stroke even 4 hours after stroke onset [4].
Another experimental study also demonstrated that moderate- to high-
dose human albumin treatment of transient focal cerebral ischemia can
improve neurologic function in animals, but the effect was not observed
in permanent focal cerebral ischemia [33]. However, Ginsberg et al [2]
did not confirm that high-dose albumin treatment can improve neurologic
function in patients with acute ischemic stroke. Considering the
conflicting results obtained from different groups, more studies are
required to validate the relations between albumin therapy and ische-
mic stroke.
Few researches have been designed to investigate the effect of albu-
min level on recurrent ischemic stroke. Our study showed that albumin
level on admission was negatively correlated with recurrence of acute
ischemic stroke. However, some limitations in our study should not be
overlooked. Firstly, the period of follow-up is relatively short, and the
incidence of death is too low to confirm the correlation between mortal-
ity and albumin level. Secondly, the information on location and size of
infarction in some patients was lost. Therefore, the data about albumin
level at 1 year after stroke were not collected.
5. Conclusion
Hypoalbuminemia or low albumin level on admission was an inde-
pendent predictor of 1-year recurrence of acute ischemic stroke, and
the recurrence of stroke increases with the decreased albumin level,
suggesting that albumin level might be used as an indicator for evalua-
tion of ischemic stroke recurrence.
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