老年营养风险指数对老年急性脑梗死患者静脉溶栓短期转归的预测价值

doi:10.3969/j.issn.1004-583X.2025.01.003

摘要/Abstract

摘要：

目的评价老年营养风险指数(GNRI)对老年急性缺血性卒中(acute ischemic stroke,AIS)阿替普酶静脉溶栓治疗患者短期转归的预测价值。方法对天津市北辰医院自2021年7月-2024年1月进行阿替普酶静脉溶栓的773例老年AIS患者进行回顾性研究,根据其临床数据计算GNRI,并对其营养状态进行评价。应用改良的Rankin (mRS)评分对患者转归进行评估,其中转归不良组(mRS评分>2分)575例,转归良好组 (mRS评分≤2分) 198例。对GNRI与短期转归的关系进行logistic回归分析。结果转归不良组GNRI明显低于转归良好组[90.106(84.622, 98.141) vs 90.722(82.239, 100.055), P<0.01]。多因素logistic回归结果表明:年龄、入院美国国立卫生研究院卒中量表(NIHSS)评分、心源性栓塞型(TOAST病因分型)、出血转化、体质量指数和低GNRI是短期转归不良的独立影响因子(P<0.01)。GNRI预测老年AIS患者静脉溶栓预后的ROC曲线下区域面积为0.876(95%CI: 0.845~0.907)。结论 GNRI是老年AIS患者营养不良与静脉溶栓后转归不良的独立风险因素并且GNRI可以作为一个重要的指标来评估老年AIS患者的免疫营养状况。

关键词: 卒中, 老年营养风险指数, 血栓溶解疗法, 转归

Abstract:

Objective To evaluate the value of Geriatric Nutritional Risk Index (GNRI) in predicting the short-term outcome of elderly patients with acute ischemic stroke (AIS) after intravenous thrombolysis with alteplase. Methods A retrospective study was performed in 773 elderly AIS patients treated with alteplase intravenous thrombolytic therapy from July 2021 to January 2024 at Beichen Hospital in Tianjin, China. GNRI was calculated based on clinical data, and the nutritional status was assessed. Patients were evaluated with a modified Rankin score (mRS), and 575 patients were included in the poor outcome group (mRS score>2) and 198 in the good outcome group (mRS score≤2). They were further classified into the low GNRI (GNRI<92.107, n=388) and high GNRI (GNRI≥92.107, n=385) groups based on the optimal cut-off. The correlation of GNRI with short-term outcome of AIS after alteplase intravenous thrombolytic therapy was analyzed by logistic regression. Results Significantly lower GNRI was detected in the poor outcome group than the good outcome group (90.106[84.622-98.141] vs 90.722[82.239-100.055], P<0.01). Multivariate logistic regression revealed that age, the National Institutes of Health Stroke Scale (NIHSS) score on admission, the Trial Org 10172 in Acute Stroke Treatment (TOAST) classification system of cardioembolism, outcome of bleeding, body mass index (BMI), and low GNRI were independent risk factors for the short-term poor outcome of AIS after alteplase intravenous thrombolytic therapy (P<0.01). The receiver operating characteristic (ROC) curve showed that an area under the curve (AUC) of GNRI predicting the prognosis of intravenous thrombolysis in elderly AIS patients is 0.876(95%CI: 0.845-0.907). Conclusion GNRI, as an independent risk factor for malnutrition and inadequate regression after intravenous thrombolysis in elderly AIS patients, is a promising indicator for assessing immune and nutritional status in this population.

Key words: stroke, geriatric nutritional risk index, thrombolytic therapy, prognosis

中图分类号:

R743

刘金华, 王春梅, 王莹, 陈凯. 老年营养风险指数对老年急性脑梗死患者静脉溶栓短期转归的预测价值[J]. 临床荟萃, 2025, 40(1): 21-28.

Liu Jinhua, Wang Chunmei, Wang Ying, Chen Kai. The potential of geriatric nutritional risk index in predicting the short-term outcome of intravenous thrombolysis in elderly individuals with acute cerebral infarction[J]. Clinical Focus, 2025, 40(1): 21-28.

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链接本文: https://huicui.hebmu.edu.cn/CN/10.3969/j.issn.1004-583X.2025.01.003

https://huicui.hebmu.edu.cn/CN/Y2025/V40/I1/21

图/表 5

表1 2组一般资料比较

Tab.1 General information between the two groups

组别	例数	性别[例(%)]				吸烟 [例(%)]		饮酒 [例(%)]		年龄 (年)		BMI (kg/m²)		高血压 [例(%)]
组别	例数	男		女		吸烟 [例(%)]		饮酒 [例(%)]		年龄 (年)		BMI (kg/m²)		高血压 [例(%)]
转归良好组	575	263(45.7)		312(54.3)		127(22.1)		109(19.0)		69.00±8.59		28.06±2.59		486(84.5)
转归不良组	198	86(43.4)		112(56.6)		36(18.2)		37(18.7)		75.14±4.63		25.78±3.62		164(82.8)
$t$ /χ²值		0.316				1.350		2.174		9.570		9.565		0.316
$P$ 值		0.574				0.245		0.337		<0.001		<0.001		0.574
组别	糖尿病 [例(%)]		脑卒中/TIA [例(%)]		冠状动脉疾病 [例(%)]		心房颤动 [例(%)]		SAO [例(%)]		LAA [例(%)]		CE [例(%)]		UND [例(%)]
转归良好组	202(35.1)		109(19.0)		155(27.0)		51(8.9)		222(38.6)		210(36.5)		112(19.5)		31(5.4)
转归不良组	73(36.9)		42(21.2)		57(28.8)		20(10.1)		51(25.8)		92(46.5)		40(20.2)		15(7.6)
χ²值	0.194		0.477		0.248		0.268		11.835
$P$ 值	0.659		0.490		0.618		0.605		0.008

表1 2组一般资料比较

Tab.1 General information between the two groups

组别	例数	性别[例(%)]				吸烟 [例(%)]		饮酒 [例(%)]		年龄 (年)		BMI (kg/m²)		高血压 [例(%)]
组别	例数	男		女		吸烟 [例(%)]		饮酒 [例(%)]		年龄 (年)		BMI (kg/m²)		高血压 [例(%)]
转归良好组	575	263(45.7)		312(54.3)		127(22.1)		109(19.0)		69.00±8.59		28.06±2.59		486(84.5)
转归不良组	198	86(43.4)		112(56.6)		36(18.2)		37(18.7)		75.14±4.63		25.78±3.62		164(82.8)
$t$ /χ²值		0.316				1.350		2.174		9.570		9.565		0.316
$P$ 值		0.574				0.245		0.337		<0.001		<0.001		0.574
组别	糖尿病 [例(%)]		脑卒中/TIA [例(%)]		冠状动脉疾病 [例(%)]		心房颤动 [例(%)]		SAO [例(%)]		LAA [例(%)]		CE [例(%)]		UND [例(%)]
转归良好组	202(35.1)		109(19.0)		155(27.0)		51(8.9)		222(38.6)		210(36.5)		112(19.5)		31(5.4)
转归不良组	73(36.9)		42(21.2)		57(28.8)		20(10.1)		51(25.8)		92(46.5)		40(20.2)		15(7.6)
χ²值	0.194		0.477		0.248		0.268		11.835
$P$ 值	0.659		0.490		0.618		0.605		0.008

图1 2组不同营养不良风险的发生率

Fig.1 Incidence of different malnutrition risks between the two groups

表2 2组临床指标比较

Tab.2 Clinical indicators between the two groups

组别	例数	NIHSS评分 (分)	发病到溶栓时间(h)		出血转化 [例(%)]		白细胞 (10⁹/L)		血红蛋白 (g/L)			尿素氮 (mmol/L)
转归良好组	575	4(2, 7)	3.2(2.4, 3.8)		12(2.1)		7.7(5.8, 7.7)		147.19±23.28			4.065(3.7, 5.53)
转归不良组	198	9(6, 12)	3.7(2.5, 3.9)		34(17.2)		7.7(6.2, 7.7)		142.69±26.19			4.59(3.7, 6.015)
χ²/ $Z$ 值		9.952	3.516		59.882		0.734		2.272			2.426
$P$ 值		<0.001	<0.001		<0.001		0.463		0.023			0.015
组别	淋巴细胞 (10⁹/L)			LDL-C (mmol/L)		白蛋白 (g/L)		肌酐 (μmol/L)		空腹血糖 (mmol/L)	GNRI (分)
转归良好组	2.148(1.898, 2.253)			2.98(2.33, 3.70)		39.4(36.3, 42.7)		51(51, 64)		5.2(4.8, 5.4)	90.722(82.239, 100.055)
转归不良组	2.148(2.067, 2.204)			3.05(2.3, 3.81)		39.9(35.7, 43)		51(51, 62)		5.2(5.2, 5.3)	90.106(84.622, 98.141)
$Z$ 值	1.247			0.648		0.708		1.272		1.384	6.108
$P$ 值	0.212			0.517		0.479		0.203		0.166	<0.001

表2 2组临床指标比较

Tab.2 Clinical indicators between the two groups

组别	例数	NIHSS评分 (分)	发病到溶栓时间(h)		出血转化 [例(%)]		白细胞 (10⁹/L)		血红蛋白 (g/L)			尿素氮 (mmol/L)
转归良好组	575	4(2, 7)	3.2(2.4, 3.8)		12(2.1)		7.7(5.8, 7.7)		147.19±23.28			4.065(3.7, 5.53)
转归不良组	198	9(6, 12)	3.7(2.5, 3.9)		34(17.2)		7.7(6.2, 7.7)		142.69±26.19			4.59(3.7, 6.015)
χ²/ $Z$ 值		9.952	3.516		59.882		0.734		2.272			2.426
$P$ 值		<0.001	<0.001		<0.001		0.463		0.023			0.015
组别	淋巴细胞 (10⁹/L)			LDL-C (mmol/L)		白蛋白 (g/L)		肌酐 (μmol/L)		空腹血糖 (mmol/L)	GNRI (分)
转归良好组	2.148(1.898, 2.253)			2.98(2.33, 3.70)		39.4(36.3, 42.7)		51(51, 64)		5.2(4.8, 5.4)	90.722(82.239, 100.055)
转归不良组	2.148(2.067, 2.204)			3.05(2.3, 3.81)		39.9(35.7, 43)		51(51, 62)		5.2(5.2, 5.3)	90.106(84.622, 98.141)
$Z$ 值	1.247			0.648		0.708		1.272		1.384	6.108
$P$ 值	0.212			0.517		0.479		0.203		0.166	<0.001

表3 AIS患者静脉溶栓短期转归危险因素的多因素logistic回归分析

Tab.3 Multivariate logistic regression analysis of risk factors for short-term outcomes of intravenous thrombolysis in AIS patients

项目	回归系数	标准误	Wald χ²值	$P$ 值	$O R$ 值	95% $C I$
项目	回归系数	标准误	Wald χ²值	$P$ 值	$O R$ 值	下限	上限
年龄	0.195	0.018	85.709	<0.001	1.215	1.166	1.266
入院NIHSS评分	0.137	0.023	33.464	<0.001	1.417	1.095	1.202
TOAST病因分型
SAO	-		4.611	0.025	-	-
LAA	0.595	0.650	1.066	0.302	1.814	0.586	5.614
CE	1.214	0.639	4.696	0.030	3.367	1.123	10.096
UND	0.636	0.669	1.144	0.285	1.889	0.589	6.057
出血转化	0.216	0.057	34.831	<0.001	1.241	1.155	1.333
BMI	-2.328	0.048	18.922	<0.001	0.097	0.034	0.278
低GNRI	0.739	0.243	10.181	0.001	2.093	1.330	3.295

表3 AIS患者静脉溶栓短期转归危险因素的多因素logistic回归分析

Tab.3 Multivariate logistic regression analysis of risk factors for short-term outcomes of intravenous thrombolysis in AIS patients

项目	回归系数	标准误	Wald χ²值	$P$ 值	$O R$ 值	95% $C I$
项目	回归系数	标准误	Wald χ²值	$P$ 值	$O R$ 值	下限	上限
年龄	0.195	0.018	85.709	<0.001	1.215	1.166	1.266
入院NIHSS评分	0.137	0.023	33.464	<0.001	1.417	1.095	1.202
TOAST病因分型
SAO	-		4.611	0.025	-	-
LAA	0.595	0.650	1.066	0.302	1.814	0.586	5.614
CE	1.214	0.639	4.696	0.030	3.367	1.123	10.096
UND	0.636	0.669	1.144	0.285	1.889	0.589	6.057
出血转化	0.216	0.057	34.831	<0.001	1.241	1.155	1.333
BMI	-2.328	0.048	18.922	<0.001	0.097	0.034	0.278
低GNRI	0.739	0.243	10.181	0.001	2.093	1.330	3.295

图2 GNRI预测老年AIS患者短期转归不良的ROC曲线

Fig.2 ROC curve of GNRI in predicting short-term poor outcomes in elderly AIS patients

参考文献 33

[1]	GBD 2016 Neurology Collaborators. Global, regional, and national burden of neurological disorders, 1990-2016: A systematic analysis for the global burden of disease study 2016[J]. Lancet Neurol, 2019, 18(5): 459-480. doi: S1474-4422(18)30499-X pmid: 30879893
[2]	Wang YJ, Li ZX, Gu HQ, et al. China stroke statistics: An update on the 2019 report from the National Center for Healthcare Quality Management in Neurological Diseases, China National Clinical Research Center for Neurological Diseases, the Chinese Stroke Association, National Center for Chronic and Non-communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention and Institute for Global Neuroscience and Stroke Collaborations[J]. Stroke Vasc Neurol, 2022, 7(5): 415-450.
[3]	Wang W, Jiang B, Sun H, et al. Prevalence, incidence, and mortality of stroke in China: Results from a nationwide population-based survey of 480 687 adults[J]. Circulation, 2017, 135(8): 759-771.
[4]	Dávalos A, Ricart W, Gonzalez-Huix F, et al. Effect of malnutrition after acute stroke on clinical outcome[J]. Stroke, 1996, 27(6): 1028-1032. pmid: 8650709
[5]	Martineau J, Bauer JD, Isenring E, et al. Malnutrition determined by the patient-generated subjective global assessment is associated with poor outcomes in acute stroke patients[J]. Clin Nutr, 2005, 24(6): 1073-1077. pmid: 16213064
[6]	Poor nutritional status on admission predicts poor outcomes after stroke: Observational data from the FOOD trial[J]. Stroke, 2003, 34(6): 1450-1456. doi: 10.1161/01.STR.0000074037.49197.8C pmid: 12750536
[7]	Schuetz P, Fehr R, Baechli V, et al. Individualised nutritional support in medical inpatients at nutritional risk: A randomised clinical trial[J]. Lancet, 2019, 393(10188): 2312-2321. doi: S0140-6736(18)32776-4 pmid: 31030981
[8]	Cederholm T, Bosaeus I, Barazzoni R, et al. Diagnostic criteria for malnutrition - an ESPEN consensus statement[J]. Clin Nutr, 2015, 34(3): 335-340. doi: 10.1016/j.clnu.2015.03.001 pmid: 25799486
[9]	Jensen GL, Cederholm T, Correia M, et al. GLIM criteria for the diagnosis of malnutrition: A consensus report from the Global Clinical Nutrition Community[J]. JPEN J Parenter Enteral Nutr, 2019, 43(1): 32-40. doi: 10.1002/jpen.1440 pmid: 30175461
[10]	Bouillanne O, Morineau G, Dupont C, et al. Geriatric nutritional risk index: A new index for evaluating at-risk elderly medical patients[J]. Am J Clin Nutr, 2005, 82(4): 777-783. doi: 10.1093/ajcn/82.4.777 pmid: 16210706
[11]	中华医学会神经病学分会, 中华医学会神经病学分会脑血管病学组. 中国急性缺血性脑卒中诊治指南2018[J]. 中华神经科杂志, 2018, 51(9): 666-682.
[12]	中华医学会神经病学分会, 中华医学会神经病学分会脑血管病学组. 中国急性脑梗死后出血转化诊治共识2019[J]. 中华神经科杂志, 2019, 52(4): 252-265.
[13]	Bamford JM, Sandercock PA, Warlow CP, et al. Interobserver agreement for the assessment of handicap in stroke patients[J]. Stroke, 1989, 20(6): 828. doi: 10.1161/01.str.20.6.828 pmid: 2728057
[14]	Adams HP Jr, Bendixen BH, Kappelle LJ, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in acute stroke treatment[J]. Stroke, 1993, 24(1): 35-41. doi: 10.1161/01.str.24.1.35 pmid: 7678184
[15]	Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: A report of the American College of Cardiology/American Heart Association task force on practice guidelines and the obesity society[J]. J Am Coll Cardiol, 2014, 63(25 Pt B): 2985-3023. doi: 10.1016/j.jacc.2013.11.004 pmid: 24239920
[16]	Zhang G, Pan Y, Zhang R, et al. Prevalence and prognostic significance of malnutrition risk in patients with acute ischemic stroke: Results from the Third China National Stroke Registry[J]. Stroke, 2022, 53(1): 111-119.
[17]	Zhang M, Ye S, Huang X, et al. Comparing the prognostic significance of nutritional screening tools and ESPEN-DCM on 3-month and 12-month outcomes in stroke patients[J]. Clin Nutr, 2021, 40(5): 3346-3353. doi: 10.1016/j.clnu.2020.11.001 pmid: 33221053
[18]	Nishioka S, Omagari K, Nishioka E, et al. Concurrent and predictive validity of the mini nutritional assessment short-form and the geriatric nutritional risk index in older stroke rehabilitation patients[J]. J Hum Nutr Diet, 2020, 33(1): 12-22. doi: 10.1111/jhn.12699 pmid: 31435986
[19]	Chen N, Li Y, Fang J, et al. Risk factors for malnutrition in stroke patients: A meta-analysis[J]. Clin Nutr, 2019, 38(1): 127-135. doi: S0261-5614(17)31434-6 pmid: 29310894
[20]	Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 Update to the 2018 guidelines for the early management of acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association[J]. Stroke, 2019, 50(12): e344-e418.
[21]	Burgos R, Bretón I, Cereda E, et al. ESPEN guideline clinical nutrition in neurology[J]. Clin Nutr, 2018, 37(1): 354-396. doi: S0261-5614(17)30318-7 pmid: 29274834
[22]	Dennis M, Lewis S, Cranswick G, et al. FOOD: A multicentre randomised trial evaluating feeding policies in patients admitted to hospital with a recent stroke[J]. Health Technol Assess, 2006, 10(2): iii-iv, ix-x, 1-120.
[23]	Gao J, Zhao Y, Du M, et al. Serum albumin levels and clinical outcomes among ischemic stroke patients treated with endovascular thrombectomy[J]. Neuropsychiatr Dis Treat, 2021, 17: 401-411.
[24]	Löwhagen Hendén P, Rentzos A, Karlsson JE, et al. Hypotension during endovascular treatment of ischemic stroke is a risk factor for poor neurological outcome[J]. Stroke, 2015, 46(9): 2678-2680. doi: 10.1161/STROKEAHA.115.009808 pmid: 26173727
[25]	Park HP, Nimmagadda A, DeFazio RA, et al. Albumin therapy augments the effect of thrombolysis on local vascular dynamics in a rat model of arteriolar thrombosis: A two-photon laser-scanning microscopy study[J]. Stroke, 2008, 39(5): 1556-1562.
[26]	Reinhart WH, Nagy C. Albumin affects erythrocyte aggregation and sedimentation[J]. Eur J Clin Invest, 1995, 25(7): 523-528. pmid: 7556371
[27]	Jickling GC, Liu D, Stamova B, et al. Hemorrhagic transformation after ischemic stroke in animals and humans[J]. J Cereb Blood Flow Metab, 2014, 34(2): 185-199.
[28]	Zoellner H, Höfler M, Beckmann R, et al. Serum albumin is a specific inhibitor of apoptosis in human endothelial cells[J]. J Cell Sci, 1996, 109(Pt 10): 2571-2580.
[29]	Spinella R, Sawhney R, Jalan R. Albumin in chronic liver disease: Structure, functions and therapeutic implications[J]. Hepatol Int, 2016, 10(1): 124-132. doi: 10.1007/s12072-015-9665-6 pmid: 26420218
[30]	Che R, Huang X, Zhao W, et al. Low serum albumin level as a predictor of hemorrhage transformation after intravenous thrombolysis in ischemic stroke patients[J]. Sci Rep, 2017, 7(1): 7776. doi: 10.1038/s41598-017-06802-y pmid: 28798356
[31]	Naito H, Hosomi N, Nezu T, et al. Prognostic role of the controlling nutritional status score in acute ischemic stroke among stroke subtypes[J]. J Neurol Sci, 2020, 416: 116984.
[32]	Gensicke H, Zinkstok SM, Roos YB, et al. IV thrombolysis and renal function[J]. Neurology, 2013, 81(20): 1780-1788. doi: 10.1212/01.wnl.0000435550.83200.9e pmid: 24122182
[33]	Lussier G, Evans AJ, Houston I, et al. Compact arterial monitoring device use in resuscitative endovascular balloon occlusion of the aorta (REBOA): A simple validation study in swine[J]. Cureus, 2024, 16(10): e70789.