{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,4]],"date-time":"2026-09-04T05:17:10Z","timestamp":1788499030064,"version":"build-2803163510"},"reference-count":43,"publisher":"MDPI AG","issue":"17","license":[{"start":{"date-parts":[[2026,8,31]],"date-time":"2026-08-31T00:00:00Z","timestamp":1788134400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100001809","name":"National Natural Science Foundation of China","doi-asserted-by":"publisher","award":["82370840"],"award-info":[{"award-number":["82370840"]}],"id":[{"id":"10.13039\/501100001809","id-type":"DOI","asserted-by":"publisher"}]},{"award":["82370840"],"award-info":[{"award-number":["82370840"]}],"id":[{"id":"https:\/\/ror.org\/01h0zpd94","id-type":"ROR","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Int. J. Mol. Sci.","IJMS"],"abstract":"<jats:p>Erythritol is a widely used low-calorie sugar substitute, but its relationship with cerebrovascular risk remains uncertain. We investigated the association between genetically predicted erythritol levels and ischemic stroke and explored stroke-related molecular features using an integrative bioinformatics framework. Two-sample and multivariable Mendelian randomization were performed across cardiovascular\u2013kidney\u2013metabolic outcomes, followed by target prediction, enrichment and protein\u2013protein interaction analyses, transcriptomic profiling, machine-learning feature selection, SHAP interpretation, immune-cell analysis, gene set variation analysis, and exploratory molecular docking. Genetically predicted erythritol showed the strongest association with stroke among the tested sweetener-related traits (OR = 1.246, 95% CI: 1.101\u20131.410, p &lt; 0.001) and remained significant after adjustment for selected hemodynamic, glycometabolic, and lipid-related traits. Downstream analyses highlighted inflammatory, oxidative-stress, hypoxic, and vascular-injury pathways and prioritized MMP9, TLR4, and HIF1A as a reproducible stroke-related three-gene signature. These downstream bioinformatic findings are exploratory and do not establish erythritol-specific molecular regulation. Overall, the results support an association between genetically predicted erythritol levels and ischemic stroke and identify candidate pathways and genes for further investigation; the MR exposure should not be interpreted as direct evidence that dietary erythritol intake causes stroke.<\/jats:p>","DOI":"10.3390\/ijms27177811","type":"journal-article","created":{"date-parts":[[2026,9,1]],"date-time":"2026-09-01T09:48:36Z","timestamp":1788256116000},"page":"7811","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Risk of Erythritol-Associated Ischemic Stroke: Integrated Genetic, Transcriptomic, and Machine Learning Evidence"],"prefix":"10.3390","volume":"27","author":[{"given":"Ao","family":"Zhong","sequence":"first","affiliation":[{"name":"Department of Endocrinology, Institute of Geriatrics, Key Laboratory of Vascular Aging of the Ministry of Education, Liyuan Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430077, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fangyang","family":"Yu","sequence":"additional","affiliation":[{"name":"Department of Endocrinology, Institute of Geriatrics, Key Laboratory of Vascular Aging of the Ministry of Education, Liyuan Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430077, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chuyue","family":"Xia","sequence":"additional","affiliation":[{"name":"Department of Endocrinology, Institute of Geriatrics, Key Laboratory of Vascular Aging of the Ministry of Education, Liyuan Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430077, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xiang","family":"Ma","sequence":"additional","affiliation":[{"name":"Department of Endocrinology, Institute of Geriatrics, Key Laboratory of Vascular Aging of the Ministry of Education, Liyuan Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430077, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Qiucheng","family":"Zhu","sequence":"additional","affiliation":[{"name":"Department of Endocrinology, Institute of Geriatrics, Key Laboratory of Vascular Aging of the Ministry of Education, Liyuan Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430077, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peilin","family":"Du","sequence":"additional","affiliation":[{"name":"Department of Endocrinology, Institute of Geriatrics, Key Laboratory of Vascular Aging of the Ministry of Education, Liyuan Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430077, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ruonan","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Endocrinology, Institute of Geriatrics, Key Laboratory of Vascular Aging of the Ministry of Education, Liyuan Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430077, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Si","family":"Jin","sequence":"additional","affiliation":[{"name":"Department of Endocrinology, Institute of Geriatrics, Key Laboratory of Vascular Aging of the Ministry of Education, Liyuan Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430077, China"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,31]]},"reference":[{"key":"ref_1","first-page":"4","article-title":"Human and economic burden of stroke","volume":"38","year":"2009","journal-title":"Age Ageing"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"200","DOI":"10.1007\/s11906-011-0195-x","article-title":"Vascular mechanisms in the pathogenesis of stroke","volume":"13","author":"Sierra","year":"2011","journal-title":"Curr. Hypertens. Rep."},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Brown, R., Allan, S.M., and Markus, H.S. (2026). The role of inflammation in cerebral small vessel disease and vascular cognitive impairment, and therapeutic implications. Int. J. Stroke, 17474930261461366.","DOI":"10.1177\/17474930261461366"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"692","DOI":"10.1161\/STROKEAHA.124.049079","article-title":"Proteins Involved in Endothelial Function and Inflammation Are Implicated in Cerebral Small Vessel Disease","volume":"56","author":"Sun","year":"2025","journal-title":"Stroke"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1","DOI":"10.3945\/ajcn.2008.26792","article-title":"Nonnutritive sweetener consumption in humans: Effects on appetite and food intake and their putative mechanisms","volume":"89","author":"Mattes","year":"2009","journal-title":"Am. J. Clin. Nutr."},{"key":"ref_6","unstructured":"WHO (2023). WHO Guidelines Approved by the Guidelines Review Committee. Use of Non-Sugar Sweeteners: WHO Guideline, World Health Organization."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"102837","DOI":"10.1016\/j.cpcardiol.2024.102837","article-title":"High consumption of artificially sweetened beverages and associated risk of cardiovascular events: A systematic review and meta-analysis","volume":"50","author":"Queiroz","year":"2025","journal-title":"Curr. Probl. Cardiol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1636","DOI":"10.1161\/CIR.0000000000001186","article-title":"A Synopsis of the Evidence for the Science and Clinical Management of Cardiovascular-Kidney-Metabolic (CKM) Syndrome: A Scientific Statement From the American Heart Association","volume":"148","author":"Ndumele","year":"2023","journal-title":"Circulation"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"e347","DOI":"10.1161\/CIR.0000000000001209","article-title":"2024 Heart Disease and Stroke Statistics: A Report of US and Global Data from the American Heart Association","volume":"149","author":"Martin","year":"2024","journal-title":"Circulation"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"k601","DOI":"10.1136\/bmj.k601","article-title":"Reading Mendelian randomisation studies: A guide, glossary, and checklist for clinicians","volume":"362","author":"Davies","year":"2018","journal-title":"BMJ"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"a040501","DOI":"10.1101\/cshperspect.a040501","article-title":"Mendelian Randomization: Concepts and Scope","volume":"12","author":"Richmond","year":"2022","journal-title":"Cold Spring Harb. Perspect. Med."},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Mazi, T.A., and Stanhope, K.L. (2023). Erythritol: An In-Depth Discussion of Its Potential to Be a Beneficial Dietary Component. Nutrients, 15.","DOI":"10.3390\/nu15010204"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1319","DOI":"10.1093\/cvr\/cvaf091","article-title":"Sweeteners: Erythritol, xylitol and cardiovascular risk-friend or foe?","volume":"121","author":"Arduini","year":"2025","journal-title":"Cardiovasc. Res."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"2136","DOI":"10.1161\/ATVBAHA.124.321019","article-title":"Ingestion of the Non-Nutritive Sweetener Erythritol, but Not Glucose, Enhances Platelet Reactivity and Thrombosis Potential in Healthy Volunteers-Brief Report","volume":"44","author":"Witkowski","year":"2024","journal-title":"Arterioscler. Thromb. Vasc. Biol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"251","DOI":"10.1038\/s41392-023-01504-6","article-title":"The sugar-free paradox: Cardiometabolic consequences of erythritol","volume":"8","author":"Pafili","year":"2023","journal-title":"Signal Transduct. Target. Ther."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"34408","DOI":"10.7554\/eLife.34408","article-title":"The MR-Base platform supports systematic causal inference across the human phenome","volume":"7","author":"Hemani","year":"2018","journal-title":"eLife"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"713","DOI":"10.1093\/ije\/dyy262","article-title":"An examination of multivariable Mendelian randomization in the single-sample and two-sample summary data settings","volume":"48","author":"Sanderson","year":"2019","journal-title":"Int. J. Epidemiol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"a038984","DOI":"10.1101\/cshperspect.a038984","article-title":"Multivariable Mendelian Randomization and Mediation","volume":"11","author":"Sanderson","year":"2021","journal-title":"Cold Spring Harb. Perspect. Med."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"E4233","DOI":"10.1073\/pnas.1620079114","article-title":"Erythritol is a pentose-phosphate pathway metabolite and associated with adiposity gain in young adults","volume":"114","author":"Hootman","year":"2017","journal-title":"Proc. Natl. Acad. Sci. USA"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"16095","DOI":"10.1074\/jbc.RA119.009049","article-title":"Unexpected roles for ADH1 and SORD in catalyzing the final step of erythritol biosynthesis","volume":"294","author":"Schlicker","year":"2019","journal-title":"J. Biol. Chem."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"e13960","DOI":"10.1111\/jfbc.13960","article-title":"Erythritol modulates the polarization of macrophages: Potential role of tumor necrosis factor-\u03b1 and Akt pathway","volume":"46","author":"Alamri","year":"2022","journal-title":"J. Food Biochem."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1714","DOI":"10.1161\/STROKEAHA.114.007308","article-title":"Dietary intake of sugar substitutes aggravates cerebral ischemic injury and impairs endothelial progenitor cells in mice","volume":"46","author":"Dong","year":"2015","journal-title":"Stroke"},{"key":"ref_23","first-page":"e000639","article-title":"Neutrophil Extracellular Traps in Ischemic Stroke Thrombi Are Associated Wth Poor Clinical Outcome","volume":"3","author":"Lapostolle","year":"2023","journal-title":"Stroke Vasc. Interv. Neurol."},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Zhou, H.L., Jiang, X.Z., and Ventikos, Y. (2023). Role of blood flow in endothelial functionality: A review. Front. Cell Dev. Biol., 11.","DOI":"10.3389\/fcell.2023.1259280"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1599","DOI":"10.1161\/CIRCULATIONAHA.106.603431","article-title":"Toll-like receptor 4 is involved in brain damage and inflammation after experimental stroke","volume":"115","author":"Caso","year":"2007","journal-title":"Circulation"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"9335166","DOI":"10.1155\/2023\/9335166","article-title":"TLR4 Enhances Cerebral Ischemia\/Reperfusion Injury via Regulating NLRP3 Inflammasome and Autophagy","volume":"2023","author":"Mao","year":"2023","journal-title":"Mediat. Inflamm."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"657","DOI":"10.1007\/s40263-026-01278-9","article-title":"Therapeutic Potential of PCSK9 Inhibitors in Regulating Neuroinflammation in Acute Ischemic Stroke","volume":"40","author":"Pu","year":"2026","journal-title":"CNS Drugs"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"979","DOI":"10.1007\/s12035-014-8687-8","article-title":"Association between matrix metalloproteinase family gene polymorphisms and ischemic stroke: A meta-analysis","volume":"50","author":"Wen","year":"2014","journal-title":"Mol. Neurobiol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"115609","DOI":"10.1016\/j.expneurol.2025.115609","article-title":"Investigating the therapeutic potential of nasal administration of mitochondria on blood-brain barrier integrity and vasogenic brain Edema in a rat ischemic stroke model","volume":"398","author":"Sadeghian","year":"2026","journal-title":"Exp. Neurol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"102842","DOI":"10.1016\/j.arr.2025.102842","article-title":"Bidirectional regulation of neuronal autophagy in ischemic stroke: Mechanisms and therapeutic potential","volume":"111","author":"Wu","year":"2025","journal-title":"Ageing Res. Rev."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"105605","DOI":"10.1016\/j.neuint.2023.105605","article-title":"HIF-1, an important regulator in potential new therapeutic approaches to ischemic stroke","volume":"170","author":"Vatte","year":"2023","journal-title":"Neurochem. Int."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"7724","DOI":"10.1523\/JNEUROSCI.21-19-07724.2001","article-title":"Effects of matrix metalloproteinase-9 gene knock-out on the proteolysis of blood-brain barrier and white matter components after cerebral ischemia","volume":"21","author":"Asahi","year":"2001","journal-title":"J. Neurosci."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"823","DOI":"10.1007\/s10456-021-09796-4","article-title":"Pericyte hypoxia-inducible factor-1 (HIF-1) drives blood-brain barrier disruption and impacts acute ischemic stroke outcome","volume":"24","author":"Tsao","year":"2021","journal-title":"Angiogenesis"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1473","DOI":"10.1161\/STROKEAHA.122.036946","article-title":"Neuroinflammation, Stroke, Blood-Brain Barrier Dysfunction, and Imaging Modalities","volume":"53","author":"Dijkhuizen","year":"2022","journal-title":"Stroke"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"56","DOI":"10.1038\/s42256-019-0138-9","article-title":"From Local Explanations to Global Understanding with Explainable AI for Trees","volume":"2","author":"Lundberg","year":"2020","journal-title":"Nat. Mach. Intell."},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"H\u00e4nzelmann, S., Castelo, R., and Guinney, J. (2013). GSVA: Gene set variation analysis for microarray and RNA-seq data. BMC Bioinform., 14.","DOI":"10.1186\/1471-2105-14-7"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"D587","DOI":"10.1093\/nar\/gkac963","article-title":"KEGG for taxonomy-based analysis of pathways and genomes","volume":"51","author":"Kanehisa","year":"2023","journal-title":"Nucleic Acids Res."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"453","DOI":"10.1038\/nmeth.3337","article-title":"Robust enumeration of cell subsets from tissue expression profiles","volume":"12","author":"Newman","year":"2015","journal-title":"Nat. Methods"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"361","DOI":"10.1186\/s12967-022-03562-w","article-title":"Identification of immune-related key genes in the peripheral blood of ischaemic stroke patients using a weighted gene coexpression network analysis and machine learning","volume":"20","author":"Zheng","year":"2022","journal-title":"J. Transl. Med."},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Cai, J., Ye, Z., Hu, Y., Yang, J., Wu, L., Yuan, F., Zhang, L., Chen, Q., and Zhang, S. (2022). Identification of immunogenic cell death-related gene classification patterns and immune infiltration characterization in ischemic stroke based on machine learning. Front. Cell. Neurosci., 16.","DOI":"10.3389\/fncel.2022.1094500"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"63","DOI":"10.1038\/s42003-020-01583-z","article-title":"Cerebrospinal fluid metabolomics identifies 19 brain-related phenotype associations","volume":"4","author":"Panyard","year":"2021","journal-title":"Commun. Biol."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"101325","DOI":"10.1016\/j.ajpc.2025.101325","article-title":"Associations between artificial sweeteners and cardiovascular disease, stroke, and diabetes: A Mendelian randomization study","volume":"24","author":"Fan","year":"2025","journal-title":"Am. J. Prev. Cardiol."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"W159","DOI":"10.1093\/nar\/gkac394","article-title":"CB-Dock2: Improved protein-ligand blind docking by integrating cavity detection, docking and homologous template fitting","volume":"50","author":"Liu","year":"2022","journal-title":"Nucleic Acids Res."}],"container-title":["International Journal of Molecular Sciences"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1422-0067\/27\/17\/7811\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,4]],"date-time":"2026-09-04T04:29:58Z","timestamp":1788496198000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1422-0067\/27\/17\/7811"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,31]]},"references-count":43,"journal-issue":{"issue":"17","published-online":{"date-parts":[[2026,9]]}},"alternative-id":["ijms27177811"],"URL":"https:\/\/doi.org\/10.3390\/ijms27177811","relation":{},"ISSN":["1422-0067"],"issn-type":[{"value":"1422-0067","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,31]]}}}