Association of the blood urea nitrogen to serum albumin ratio and all-cause mortality in critical ill acute ischemic stroke patients: a retrospective cohort study of MIMIC-IV database 3.0
Authors: Huang Yongwei , Li Zongping , Wang Jianjun , Wang Decai , Yin Xiaoshuang 
Published: January 2025

Purpose

We aim to ascertain the extent to which the blood urea nitrogen (BUN) to serum albumin (ALB) ratio (BAR) could be implemented to anticipate the short- and long-term prognosis of acute ischemic stroke (AIS) patients in intensive care units (ICUs).

Methods

The data was derived from the Marketplace for Intensive Care Medical Information-IV (MIMIC-IV v3.0) database, primarily pertaining to AIS patients as categorized by the International Classification of Diseases (ICD)-9 and ICD-10. The outcomes encompassed short-term ACM incorporating ICM admissions and 30-day, as well as longer-term ACM involving 90-day and 365-day. Any confounding effects were mitigated with a 1:1 propensity score matching (PSM) approach. We determined the critical BAR level affecting patient survival with the use of maximum chosen rank statistics. The connection between BAR and ACM at various time intervals was ascertained with the multivariate Cox regression (MCR) models after the adjustment for covariates. Kaplan–Meier (KM) survival curves were generated to illustrate variations in BAR and death over various time intervals. Additionally, the linear or non-linear connection between BAR and ACM was ascertained with restricted cubic spline (RCS) approaches, supplemented by interaction and subgroup analyses.

Results

Prior to PSM, we incorporated 1,764 suitable subjects with a median BAR of 5.52 mg/g. This cohort was composed of 1,395 and 369 patients in the BAR &lt;10.42 and ≥10.42 groups, respectively. The ICU ACM rates were 9.53 and 19.24% (p &lt; 0.001), respectively, while the 30-day ACM rates were 19.00 and 40.11% (p &lt; 0.001). The 90- and 365-day ACM rates were 26.95 and 52.57% (p &lt; 0.001), and 33.12 and 62.87%, respectively (p &lt; 0.001). After fully adjustment, MCR models indicated a heightened mortality risk for the ICU (hazard ratio [HR] = 1.55, 95% confidence interval [CI]: 1.08–2.22; p = 0.02), 30-day (HR = 1.87, 95% CI: 1.46–2.38; p &lt; 0.001), 90-day (HR = 1.75, 95% CI: 1.42–2.15; p &lt; 0.001), and 365-day (HR = 1.81, 95% CI: 1.50–2.19; p &lt; 0.001) in the high BAR group as opposed to the low BAR group. Following PSM, the analysis included 352 matched patient pairs, revealing persistent links between the higher BAR group and increased ACM risk throughout ICU, 30-, 90-, and 365-day intervals. Subsequent RCS studies before and after PSM highlighted a positive non-linear correlation between BAR and ACM in the short and long-term. In the subgroup investigation of ICU ACM, a subgroup of diabetes had an interaction effect (Pfor interaction = 0.02). In the subgroup analysis of 90-day ACM, subgroups of hypertension and CRRT had an interaction effect (all Pfor interaction &lt; 0.05). In the subgroup analysis of 365-day ACM, subgroups of HTN, CRRT, and malignancy tumor had an interaction effect (all Pfor interaction &lt; 0.05).

Conclusion

In this retrospective cohort study, our findings reveal that a confluence of deteriorated nutritional and renal function is significantly linked to heightened risks of ACM, and BAR may operate as an effective predictive indicator for AIS patients in ICUs. These findings have substantial importance for public health policy and practice. A comprehensive knowledge of these linkages may enable public health specialists and researchers to formulate more precisely targeted drugs and policies tailored to the unique requirements of the AIS patient group, hence improving their health outcomes. We reveal a significant link between the BAR and ACM in persons with AIS, highlighting the BAR’s potential as an innovative, economical, and accessible measure for forecasting ACM in this demographic. However, further research is needed on other racial and ethnic groups before these findings can be widely applied in clinical practice.