Plasma Klotho concentrations predict functional outcome at three months after acute ischemic stroke patients

Figures & data

Table 1. Characteristics of the study subjects according to quartile of plasma Klotho concentrations.

	Total (n = 262)	Klotho quartile				p Value
		Quartile 1 (n = 65)	Quartile 2 (n = 66)	Quartile 3 (n = 66)	Quartile 4 (n = 65)
Plasma Klotho, pg/mL	312.7 ± 153.3	149.7 ± 29.1	242.9 ± 23.2	337.1 ± 26.7	522.1 ± 128.8	–
Demographics
Sex, male	152 (58.0)	34 (52.3)	40 (60.6)	40 (60.6)	38 (58.5)	.744
Age, years	64.7 ± 12.3	67.6 ± 13.5	63.9 ± 11.0	63.5 ± 12.3	63.8 ± 12.1	.186
Body mass index, kg/m^2	24.0 ± 3.3	23.5 ± 3.1	24.4 ± 3.6	23.8 ± 3.2	24.3 ± 3.4	.379
Risk factors
Hypertension	153 (58.4)	39 (60.0)	36 (54.5)	41 (62.1)	37 (56.9)	.824
Diabetes mellitus	108 (41.2)	26 (40.0)	30 (45.5)	25 (37.9)	27 (41.5)	.841
Hypercholesterolemia	74 (28.2)	19 (29.2)	15 (22.7)	24 (36.4)	16 (24.6)	.309
Coronary artery disease	47 (17.9)	16 (24.6)	12 (18.2)	10 (15.2)	9 (13.8)	.383
Smoking	98 (37.4)	21 (32.3)	26 (39.4)	24 (36.4)	27 (41.5)	.720
Alcohol intake	73 (27.9)	19 (29.2)	21 (31.8)	21 (31.8)	12 (18.5)	.267
Prior medication
Antithrombotics	55 (21.0)	18 (27.7)	16 (24.2)	10 (15.2)	11 (16.9)	.242
Statins	53 (20.2)	13 (20.0)	13 (19.7)	13 (29.7)	14 (21.5)	.993
NIHSS	3 [2–6]	6 [2–8]	3 [2–6]	3 [1–5]	3 [2–5]	.002
Cerebral infarction volume, ×10^3, mm^3	2.9 ± 7.9	5.0 ± 10.2	3.9 ± 9.7	1.6 ± 5.3	0.9 ± 3.9	<.001
Cerebral atherosclerosis	113 (43.1)	38 (58.5)	29 (43.9)	23 (34.8)	23 (35.4)	.021
High-grade white matter hyperintensities	64 (24.4)	20 (30.8)	20 (30.3)	16 (24.2)	8 (12.3)	.050
Stroke subtype						.324
Cardioembolism	47 (17.9)	14 (21.5)	12 (18.2)	9 (13.6)	12 (18.5)	–
Large artery atherosclerosis	108 (41.2)	31 (47.7)	21 (31.8)	31 (47.0)	25 (38.5)	–
Small vessel occlusion	107 (40.8)	20 (30.8)	33 (50.0)	26 (39.4)	28 (43.1)	–
Blood laboratory findings
Fibroblast growth factor-23, pg/mL	347.5 ± 549.6	797.6 ± 923.0	209.7 ± 267.5	205.9 ± 137.0	181.2 ± 119.5	<.001
Vitamin D 25(OH)D, ng/mL	20.1 ± 6.8	19.1 ± 6.4	20.9 ± 7.6	19.9 ± 6.6	20.6 ± 6.6	.416
Fasting glucose, mg/dL	116.2 ± 42.3	112.7 ± 34.0	119.2 ± 42.8	125.6 ± 56.4	107.1 ± 29.4	.071
HbA1c, %	6.5 ± 1.4	6.4 ± 1.1	6.4 ± 1.1	6.6 ± 2.0	6.6 ± 1.3	.595
Triglyceride, mg/dL	129.0 ± 95.6	141.6 ± 91.3	123.8 ± 70.0	127.7 ± 82.5	122.8 ± 129.7	.659
Total cholesterol, mg/dL	177.5 ± 38.9	181.1 ± 42.3	173.3 ± 32.6	180.0 ± 44.8	175.7 ± 35.0	.631
Low density lipoprotein, mg/dL	115.0 ± 36.9	116.1 ± 42.5	116.0 ± 30.2	114.8 ± 41.8	113.0 ± 32.1	.961
White blood cell count, ×10^3	7.3 ± 2.4	7.9 ± 2.7	7.8 ± 2.7	6.5 ± 1.7	7.2 ± 2.2	.004
Haemoglobin, mg/dL	13.5 ± 1.6	13.1 ± 1.6	13.6 ± 1.5	13.3 ± 1.5	13.8 ± 1.6	.097
Creatinine, mg/dL	1.0 ± 0.8	1.2 ± 1.2	0.9 ± 0.2	1.0 ± 1.0	0.8 ± 0.1	.083
Total calcium, mg/dL	8.3 ± 0.4	8.2 ± 0.4	8.2 ± 0.4	8.2 ± 0.4	8.2 ± 0.4	.925
Phosphate, mg/dL	3.1 ± 0.6	3.1 ± 0.6	3.1 ± 0.5	3.1 ± 0.5	3.1 ± 0.6	.946
Albumin, mg/dL	3.7 ± 0.3	3.6 ± 0.4	3.7 ± 0.3	3.7 ± 0.3	3.7 ± 0.3	.257
Alkaline phosphatase, IU/L	224.4 ± 72.2	219.9 ± 73.5	219.5 ± 70.4	236.0 ± 71.8	222.0 ± 73.4	.506
Uric acid, mg/dL	4.8 ± 1.6	4.9 ± 2.0	5.2 ± 1.6	4.5 ± 1.5	4.7 ± 1.1	.075
C-reactive protein, mg/L	0.9 ± 2.8	1.2 ± 2.1	1.1 ± 4.5	0.7 ± 1.6	0.7 ± 1.8	.609

Data are shown as n (%), mean ± standard deviation, or median [interquartile range].

NIHSS: National Institutes of Health Stroke Scale.

Table 2. Comparison of clinical and brain image findings according to clinical outcome at three months after index stroke.

	mRS <3 (n = 204)	mRS ≥3 (n = 58)	p Value
Demographics
Sex, male	123 (60.3)	29 (50.0)	.161
Age, years	63.5 ± 11.8	69.1 ± 13.0	.002
Body mass index, kg/m^2	24.1 ± 3.3	23.8 ± 3.6	.552
Risk factors
Hypertension	117 (57.4)	36 (62.1)	.520
Diabetes mellitus	86 (42.2)	22 (37.9)	.564
Hypercholesterolemia	60 (29.4)	14 (24.1)	.431
Coronary artery disease	35 (17.2)	12 (20.7)	.536
Smoking	80 (39.2)	18 (31.0)	.256
Alcohol intake	58 (28.4)	15 (25.9)	.700
Prior medication
Antithrombotics	39 (19.1)	16 (27.6)	.162
Statins	46 (22.5)	7 (12.1)	.080
NIHSS	3 [1–5]	8 [6–13]	.001
Cerebral infarction volume, ×10^3, mm^3	0.4 ± 1.0	11.4 ± 13.8	.001
Cerebral atherosclerosis	79 (38.7)	34 (58.6)	.007
High-grade white matter hyperintensities	46 (22.5)	18 (31.0)	.184
Stroke subtype			.001
Cardioembolism	29 (14.2)	18 (31.0)	–
Large artery atherosclerosis	81 (39.7)	27 (46.6)	–
Small vessel occlusion	94 (46.1)	13 (22.4)	–
Blood laboratory findings
Klotho, pg/mL	342.5 ± 153.5	207.8 ± 96.2	.001
Fibroblast growth factor-23, pg/mL	230.5 ± 229.7	759.1 ± 986.9	.001
Vitamin D 25(OH)D, ng/mL	20.2 ± 7.0	19.8 ± 6.1	.696
Fasting glucose, mg/dL	116.3 ± 43.6	115.7 ± 37.9	.921
HbA1c, %	6.5 ± 1.4	6.6 ± 1.3	.482
Triglyceride, mg/dL	125.5 ± 101.0	141.0 ± 72.8	.277
Total cholesterol, mg/dL	175.6 ± 38.7	184.5 ± 39.2	.124
Low density lipoprotein, mg/dL	113.3 ± 35.8	121.0 ± 40.0	.160
White blood cell count, ×10^3	7.0 ± 2.2	8.5 ± 2.8	.001
Haemoglobin, mg/dL	13.5 ± 1.6	13.4 ± 1.6	.738
Creatinine, mg/dL	0.9 ± 0.6	1.1 ± 1.2	.174
Total calcium, mg/dL	8.2 ± 0.4	8.2 ± 0.4	.886
Phosphate, mg/dL	3.1 ± 0.5	3.1 ± 0.7	.759
Albumin, mg/dL	3.7 ± 0.3	3.6 ± 0.3	.210
Alkaline phosphatase, IU/L	223.4 ± 71.5	227.7 ± 74.9	.688
Uric acid, mg/dL	4.8 ± 1.4	4.9 ± 2.2	.864
C-reactive protein, mg/L	0.6 ± 1.4	2.2 ± 5.1	.001

Data are shown as n (%), mean ± standard deviation, or median [interquartile range].

mRS: modified Rankin scale; NIHSS: National Institutes of Health Stroke Scale.

Table 3. Correlation of plasma Klotho with clinical and blood laboratory findings.

Variables	Spearman’s Rho	p Value
Clinical findings for stroke severity
NIHSS	−0.253	<.001
Cerebral infarction volume	−0.223	<.001
Blood laboratory findings
Fibroblast growth factor-23, pg/mL	−0.325	.001
Vitamin D (25(OH)D), ng/mL	0.063	.312
Fasting glucose, mg/dL	−0.059	.338
HbA1c, %	0.059	.342
Triglyceride, mg/dL	−0.175	.004
Total cholesterol, mg/dL	−0.042	.500
Low density lipoprotein, mg/dL	−0.043	.485
White blood cell count, ×10^3	−0.112	.070
Haemoglobin, mg/dL	0.110	.076
Creatinine, mg/dL	−0.130	.035
Total calcium, mg/dL	−0.071	.250
Phosphate, mg/dL	0.011	.858
Albumin, mg/dL	0.054	.386
Alkaline phosphatase, IU/L	0.030	.630
Uric acid, mg/dL	−0.056	.366
C-reactive protein, mg/L	−0.181	.003

NIHSS: National Institutes of Health Stroke Scale.

Table 4. Multivariable analysis for good clinical outcome at three months after index stroke with following dependent variables.

Variables	*Odds ratio (95% confidence interval)	p Value
Sex, male	0.67 (0.21–2.10)	.493
Age, years	0.97 (0.92–1.01)	.173
Prior stroke statin use	13.05 (2.08–81.88)	.006
NIHSS	0.55 (0.44–0.69)	<.001
Cerebral atherosclerosis	2.06 (0.60–7.08)	.250
Stroke subtype
Cardioembolism	1.21 (0.29–5.11)	.792
Large artery atherosclerosis	1.43 (0.38–5.40)	.602
Small vessel occlusion	References
Plasma Klotho (per 100 unit)	2.42 (1.45–4.04)	<.001
Fibroblast growth factor-23 (per 100 unit)	0.88 (0.79–0.98)	.025
White blood cell count	0.98 (0.80–1.20)	.831
C-reactive protein	0.93 (0.76–1.13)	.454

Data are shown as odds ratio (95% confidence interval).

NIHSS: National Institutes of Health Stroke Scale.

*Adjusted for sex, age, prior stroke statin use, NIHSS, cerebral atherosclerosis, stroke subtype, fibroblast growth factor-23, white blood cell count and C-reactive protein.

Figure 1. Results of receiver operating characteristic analysis for plasma alpha-Klotho concentration. (A) Receiver-operating characteristic curve using plasma alpha-Klotho concentrations alone for investigating poor functional outcome. Black arrowhead indicates the optimal cut-off point of plasma alpha-Klotho concentrations by Youden method. (B) Change in the AUC after the addition of plasma alpha-Klotho concentrations to the multivariate model for poor functional outcome.