Reduced Vitamin D Levels are Associated with Stroke-Associated Pneumonia in Patients with Acute Ischemic Stroke

Clinical Interventions in Aging Dovepress open access to scientific and medical research Clinical Interventions in Aging downloaded from https://www.dovepress.com/ by 183.89.211.119 on 24-Apr-2020 For personal use only. Open Access Full Text Article ORIGINAL RESEARCH Reduced Vitamin D Levels are Associated with Stroke-Associated Pneumonia in Patients with Acute Ischemic Stroke This article was published in the following Dove Press journal: Clinical Interventions in Aging Gui-Qian Huang 1, * Hao-Ran Cheng 1, * Yue-Min Wu 1 Qian-Qian Cheng 2 Yu-Min Wang 3 Jia-Li Fu 3 Hui-Xin Zhou 3 Zhen Wang 1 1 Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang, People’s Republic of China; 2School of Mental Health, Wenzhou Medical University, Wenzhou 325000, Zhejiang, People’s Republic of China; 3Department of Laboratory Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang, People’s Republic of China *These authors contributed equally to this work Background and aim: Stroke-associated pneumonia (SAP) is a common complication in patients with acute ischemic stroke (AIS). This study explored the potential relationship between serum vitamin D levels and SAP. Methods: This study recruited 863 consecutive AIS patients. In-hospital SAP was defined as a complication that occurred after stroke, during hospitalization, that was confirmed radiographically. Serum vitamin D levels were measured within 24 hrs of admission and the patients were divided into vitamin D sufficient (>50 nmol/L), insufficient (25–50 nmol/L), and deficient (<25 nmol/L) groups. Results: In this study, 102 (11.8%) patients were diagnosed with SAP. Compared to the patients without SAP, patients with SAP had significantly lower vitamin D levels (P = 0.023). The incidence of SAP was significantly higher in patients with vitamin D deficiency than in those with vitamin D insufficiency or sufficiency (21.2% vs 16.2% & 9.5%, P = 0.006). After adjusting for confounders, vitamin D deficiency and insufficiency were independently associated with SAP (OR = 3.034, 95% CI = 1.207–7.625, P = 0.018; OR = 1.921, 95% CI = 1.204–3.066, P = 0.006, respectively). In multiple-adjusted spline regression, vitamin D levels showed a linear association with the risk of SAP (P < 0.001 for linearity). Conclusion: Reduced vitamin D is a potential risk factor of in-hospital SAP, which can help clinicians identify high-risk SAP patients. Keywords: acute ischemic stroke, stroke-associated pneumonia, vitamin D Introduction Correspondence: Zhen Wang Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang, People’s Republic of China Tel +86 577-555780166 Fax +86 577-55578033 Email submit your manuscript | www.dovepress.com DovePress http://doi.org/10.2147/CIA.S230255 Powered by TCPDF (www.tcpdf.org) Stroke patients are more likely to have pneumonia during hospitalization, and the prevalence of stroke-associated pneumonia (SAP) ranges from 7.1 to 31.3%.1–5 Studies have confirmed that SAP is independently associated with early mortality, prolonged hospitalization, and poor outcomes among stroke patients.1,3,6,7 To improve the prognosis of stroke patients, it is necessary to identify risk factors for SAP early, to enable preventive interventions and treatment. Vitamin D is a neurosteroid hormone that affects various diseases, including stroke, cardiovascular disease, and multiple sclerosis.8–11 Clinical studies show that low vitamin D levels are common in stroke patients due to reduced vitamin D intake, a lack of outdoor exercise, and decreased physiological synthesis.8,12–14 Furthermore, vitamin D has anti-inflammatory properties and low vitamin D levels may lead to increased inflammatory activity.15,16 Therefore, we hypothesized that a reduction in Clinical Interventions in Aging 2019:14 2305–2314 2305 © 2019 Huang et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms. php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). Dovepress Huang et al Clinical Interventions in Aging downloaded from https://www.dovepress.com/ by 183.89.211.119 on 24-Apr-2020 For personal use only. vitamin D levels might be associated with the occurrence of pneumonia after acute stroke. Given that low vitamin D levels are common in stroke patients, we aimed to explore the association between vitamin D levels and SAP in patients with acute ischemic stroke (AIS). Methods Study Design We enrolled patients form a retrospective clinical database that included consecutive patients who were admitted to the Department of Neurology, First Affiliated Hospital of Wenzhou Medical University, within 24 hrs after the onset of ischemic stroke between October 2017 and October 2018. This retrospective study was approved by the Ethics Committee of the First Affiliated Hospital of Wenzhou Medical University. Because this study was retrospective and all included data were anonymous, the requirement that patients give informed consent was waived. Inclusion and Exclusion Criteria All patients with suspected AIS were confirmed by cranial computed tomography (CT) or magnetic resonance imaging (MRI) within 24 hrs of admission. The exclusion criteria were as follows: (i) diagnosed with transient ischemic attack; (ii) active infection or pyrexia within 2 weeks before admission; (iii) preventive antibiotic therapy; (iv) history of any other central nervous system disease, such as brain trauma, cerebral hemorrhage, hydrocephalus, and Parkinson’s disease; (v) severe hepatic disease (serum transaminase concentration exceeding twice the upper limit of the reference range within 6 months or persistent hyperbilirubinemia); (vi) severe renal disease [glomerular filtration rate (GFR) < 60 mL min–1 1.73 m–2]; (vii) osteoporosis or taking vitamin D supplementation before stroke onset; and (viii) lack of complete medical and laboratory records. Ultimately, 863 patients were enrolled in this study and their data were analyzed (Figure 1). Data Collection The patients’ demographic data, including age and gender, were collected from their medical records. Baseline clinical parameters were obtained, including stroke subtype (according the TOAST criteria),17 previous stroke, dysphagia, current cigarette smoking, current alcohol consumption, and arterial blood pressure. Pre-existing comorbidities included hypertension, diabetes, coronary heart disease, and ch (...truncated)