Influence of dietary purines on pool size, turnover, and excretion of uric acid during balance conditions. Isotope studies using 15N-uric acid

Hypouricemic effect of gallic acid, a bioactive compound from Sonneratia apetala leaves and branches, on hyperuricemic mice

As a tropical medicinal plant, Sonneratia apetala is mainly distributed in the southeast coastal areas of China. Recently, the hypouricemic effect of Sonneratia apetala leaves and branches (SAL) has been reported, but the active compound and its mechanism are unclear. Thus, this study aims to explore the effective fraction of SAL and the mechanism of its active compound on uric acid formation and excretion. SAL was extracted with ethyl acetate and concentrated to obtain solvent-free extracts (SAL-EA). The remains fraction (SAL-E) and the supernatant fraction (SAL-S) of SAL resulting from water extraction and alcohol precipitation were collected and dried. The effects of different fractions were explored on hyperuricemic mice. SAL-S showed excellent activities in decreasing the levels of uric acid (UA), blood urea nitrogen (BUN), and creatinine (CRE) in serum and in attenuating kidney damage. Then, the active compound gallic acid (GA) identified by HPLC was assayed for its mechanism of regulating uric acid metabolism in hyperuricemic mice. The hypouricemic effect of GA was probably associated with the downregulation of URAT1 and GLUT9, upregulation of ABCG2 and decreased activities of adenosine deaminase (ADA) and xanthine oxidase (XOD). Moreover, GA suppressed the level of MDA, IL-6, IL-1β, TNF-α, TGF-β1, COX-2 and cystatin-C (Cys-C), and enhanced the activities of SOD, GSH-Px, CAT, and Na⁺-K⁺-ATPase (NKA) in the kidneys. These results indicated that GA protects against hyperuricemia-induced kidney injury via suppressing oxidative stress and inflammation as well as decreasing the serum levels of UA by regulating urate transporters.

Hyperuricemia and Progression of Chronic Kidney Disease: A Review from Physiology and Pathogenesis to the Role of Urate-Lowering Therapy

The relationship between hyperuricemia, gout, and renal disease has been investigated for several years. From the beginning, kidney disease has been considered a complication of gout; however, the viewpoints changed, claiming that hypertension and elevated uric acid (UA) levels are caused by decreased urate excretion in patients with renal impairment. To date, several examples of evidence support the role of hyperuricemia in cardiovascular or renal diseases. Several mechanisms have been identified that explain the relationship between hyperuricemia and chronic kidney disease, including the crystal effect, renin-angiotensin-aldosterone system activation, nitric oxide synthesis inhibition, and intracellular oxidative stress stimulation, and urate-lowering therapy (ULT) has been proven to reduce renal disease progression in the past few years. In this comprehensive review, the source and physiology of UA are introduced, and the mechanisms that explain the reciprocal relationship between hyperuricemia and kidney disease are reviewed. Lastly, current evidence supporting the use of ULT to postpone renal disease progression in patients with hyperuricemia and gout are summarized.

Hyperuricemia and Cardiovascular Disease

Purine metabolism in the circulatory system yields uric acid as its final oxidation product, which is believed to be linked to the development of gout and kidney stones. Hyperuricemia is closely correlated with cardiovascular disease, metabolic syndrome, and chronic kidney disease, as attested by the epidemiological and empirical research. In this review, we summarize the recent knowledge about hyperuricemia, with a special focus on its physiology, epidemiology, and correlation with cardiovascular disease. This review also discusses the possible positive effects of treatment to reduce urate levels in patients with cardiovascular disease and hyperuricemia, which may lead to an improved clinical treatment plan.

Physiology of Hyperuricemia and Urate-Lowering Treatments

Gout is the most common form of inflammatory arthritis and is a multifactorial disease typically characterized by hyperuricemia and monosodium urate crystal deposition predominantly in, but not limited to, the joints and the urinary tract. The prevalence of gout and hyperuricemia has increased in developed countries over the past two decades and research into the area has become progressively more active. We review the current field of knowledge with emphasis on active areas of hyperuricemia research including the underlying physiology, genetics and epidemiology, with a focus on studies which suggest association of hyperuricemia with common comorbidities including cardiovascular disease, renal insufficiency, metabolic syndrome and diabetes. Finally, we discuss current therapies and emerging drug discovery efforts aimed at delivering an optimized clinical treatment strategy.

Urate Handling in the Human Body

Elevated serum urate concentration is the primary cause of gout. Understanding the processes that affect serum urate concentration is important for understanding the etiology of gout and thereby understanding treatment. Urate handing in the human body is a complex system including three major processes: production, renal elimination, and intestinal elimination. A change in any one of these can affect both the steady-state serum urate concentration as well as other urate processes. The remarkable complexity underlying urate regulation and its maintenance at high levels in humans suggests that this molecule could potentially play an interesting role other than as a mere waste product to be eliminated as rapidly as possible.

Simultaneous determination of nucleosides and nucleotides in dietary foods and beverages using ion-pairing liquid chromatography-electrospray ionization-mass spectrometry

A method using ion-pairing liquid chromatography-electrospray ionization (ESI)-mass spectrometry (MS) was developed for the simultaneous determination of 23 types of purine or pyrimidine nucleosides and nucleotides in dietary foods and beverages. Dihexylammonium acetate (DHAA) was used as an ion-pairing agent and an ultra performance liquid chromatography (UPLC) system with a reversed-phase column and a gradient program was employed for the separation of nucleosides and nucleotides. Positive-ion ESI-MS was applied for the detection of nucleosides, and negative-ion ESI-MS was used for nucleotides. Lower limits of quantitation ranged from 0.02 micromol/L (UMP and AMP) to 1.3 micromol/L (CDP). The present method was validated, and sufficient reproducibility and accuracy was obtained for the quantitative measurement of the 23 types of nucleosides and nucleotides. The method was subsequently applied to their determination in a range of Japanese foods and beverages that are considered to contain significant amounts of umami flavor compounds. Because dietary purine nucleosides and nucleotides are known to be related to hyperuricemia and gout, the determination of their concentrations in dietary foods is useful for both evaluating umami flavor and assessing the effects of dietary food on purine metabolism.

Urinary excretion of purine derivatives inBos indicus×Bos tauruscrossbred cattle

Four experiments were performed to study the kinetics of purine metabolism and urinary excretion in Zebu crossbred cattle. Fasting excretion was established in Expt 1, using eighteen maleBos indicus×Bos tauruscrossbred cattle (261 (se 9·1) kg body weight), six of each of the following genotypes: 5/8Bos indicus, 1/2Bos indicusand 3/8Bos indicus. No significant differences were observed among genotypes in fasting purine derivative excretion (277·3 (se 35·43) μmol/metabolic body weight). In a second experiment we measured the xanthine oxidase activity, which was higher in liver than in duodenal mucosa (0·64 and 0·06 (se 0·12) units/g wet tissue per min respectively;P>0·05) being in plasma 0·60 (se 0·36) units/l per min. The kinetics of uric acid were measured by intravenous pulse dose of [1,3-15N]uric acid (Expt 3). The cumulative recovery of the isotope in urine was 82 (se 6·69) %, and uric acid plasma removal, pool size and mean retention time were 0·284 (se 0·051) per h, 5·45 (se 0·823) mmol and 3·52 (se 0·521) h, respectively. Allantoin was removed from plasma at an estimated fractional rate of 0·273 (se 0·081) per h and mean retention was 3·66 (se 1·08) h. In Expt 4, the relationship between urinary purine derivative excretion (Y; mmol/d) and digestible organic matter intake (X, kg/d) was defined by the equation:Y=7·69 (se 4·2)+5·69 (se 1·68)X;n16, Se 1·31,r0·67.

Influence of purine intake on uric acid excretion in infants fed soy infant formulas

OBJECTIVE

These studies tested the hypothesis that increasing intake of purines, delivered as RNA from soy protein-based infant formula, would increase urinary uric acid excretion in infants.

METHODS

Study One examined the influence of feeding on serum uric acid in a total of 178 infants from four separate trials with infants fed commercial and experimental soy-based and milk-based infant formulas or human milk. Studies Two and Three compared the effect of a standard purine soy formula (STD Purine; 180 mg purines/L from RNA) and a reduced purine soy formula (Reduced Purine; 65 mg purines/L; 26 mg/L from RNA and 39 mg/L from ribonucleotides) on urinary uric acid excretion in infants. In Study Two, 11 infants ranging in age from 16 to 128 days of age were fed both formulas in a random crossover design. Complete 72-hour urine collections were done at the end of each 11-day feeding period. Urinary uric acid excretion was expressed as mmol/day. In Study Three, 33 infants were enrolled before eight days of age and randomized to one of the formulas one week later. Spot urine samples were collected at 28 and/or 56 days of age and urinary uric acid concentration was expressed as mmol/mmol creatinine.

RESULTS

In Study One, each of the feedings resulted in mean serum uric acid levels within normal reference ranges. Soy formula led to higher serum uric acid levels than human milk, and human milk to levels indistinguishable from cow milk-based formulas. In Study Two, infants excreted significantly more uric acid in the urine when fed the STD Purine formula compared to the Reduced Purine formula (0.86+/-.04 vs. 0.57+/-.04 mmol/d) (p = 0.006). In Study Three, infants fed the STD Purine formula had a significantly higher concentration of uric acid in their urine compared to those fed the Reduced Purine formula (2.1+/-0.2 vs. 1.4+/-0.1 mmol uric acid/mmol creatinine) (p = 0.0001).

CONCLUSION

These data indicate that healthy infants can digest RNA and subsequently absorb the liberated purine ribonucleotides as determined by urinary uric acid concentration.

Uric acid and glutathione levels during short-term whole body cold exposure

Ten healthy subjects who swim regularly in ice-cold water during the winter (winter swimming), were evaluated before and after this short-term whole body exposure. A drastic decrease in plasma uric acid concentration was observed during and following the exposure to the cold stimulus. We hypothesize that the uric acid decrease can be caused by its consumption after formation of oxygen radicals. In addition, the erythrocytic level of oxidized glutathione and the ratio of oxidized glutathione/total glutathione also increased following cold exposure, which supports this hypothesis. Furthermore, the baseline concentration of reduced glutathione was increased and the concentration of oxidized glutathione was decreased in the erythrocytes of winter swimmers as compared to those of nonwinter swimmers. This can be viewed as an adaptation to repeated oxidative stress, and is postulated as mechanism for body hardening. Hardening is the exposure to a natural, e.g., thermal stimulus, resulting in an increased tolerance to stress, e.g., diseases. Exposure to repeated intensive short-term cold stimuli is often applied in hydrotherapy, which is used in physical medicine for hardening.

Towards the physiological function of uric acid

Uric acid, or more correctly (at physiological pH values), its monoanion urate, is traditionally considered to be a metabolically inert end-product of purine metabolism in man, without any physiological value. However, this ubiquitous compound has proven to be a selective antioxidant, capable especially of reaction with hydroxyl radicals and hypochlorous acid, itself being converted to innocuous products (allantoin, allantoate, glyoxylate, urea, oxalate). There is now evidence for such processes not only in vitro and in isolated organs, but also in the human lung in vivo. Urate may also serve as an oxidisable cosubstrate for the enzyme cyclooxygenase. As shown for the coronary system, a major site of production of urate is the microvascular endothelium, and there is generally a net release of urate from the human myocardium in vivo. In isolated organ preparations, urate protects against reperfusion damage induced by activated granulocytes, cells known to produce a variety of radicals and oxidants. Intriguingly, urate prevents oxidative inactivation of endothelial enzymes (cyclooxygenase, angiotensin converting enzyme) and preserves the ability of the endothelium to mediate vascular dilatation in the face of oxidative stress, suggesting a particular relationship between the site of urate formation and the need for a biologically potent radical scavenger and antioxidant.

Urinary caffeine metabolites in man. Age-dependent changes and pattern in various clinical situations

In an exploratory study the 24-h urinary excretion pattern of caffeine and 14 of its major metabolites was studied in 32 volunteers (adults, adolescents and children), 14 patients either with end stage renal disease or liver cirrhosis, 7 heavy smokers and 27 patients on therapy with cimetidine, allopurinol, theophylline or phenytoin. Caffeine and its metabolites were quantified by UV-absorption after liquid/liquid-extraction and HPLC-separation, which ensured proper analysis of 1-methyluric acid. In adults the renal excretion of caffeine derivatives corresponded to an intake of 509 mg caffeine/day, with 1-methyluric acid as the predominant metabolite. About 69% of caffeine was degraded by the paraxanthine pathway, and theobromine- (19%) and the theophylline pathway (14%) were less important. The ratio of paraxanthine formation to urinary caffeine concentration (= clearance equivalent) was about 2.2 ml.min-1.kg-1 in adults, and the corresponding ratios for theophylline and theobromine were 0.43 ml.min-1.kg-1 and 0.59 ml.min-1.kg-1, respectively. As expected, caffeine degradation was impaired in patients with cirrhosis and was increased in persons who smoked heavily or who were on phenytoin therapy. The results document the possibility of noninvasively investigating gross differences in caffeine disposition by analysis of the urinary pattern of its metabolites.

[Purine and pyrimidine metabolites for the estimation of rumen metabolism: HPLC analysis in milk and blood plasma]

In milk and blood plasma samples of 6 German Simmental and 12 German Black and White heifers it was investigated, whether purine and pyrimidine compounds are suitable indicators of the microbial protein synthesis in the rumen. Therefore the secreted quantities in milk and the concentration in blood plasma are correlated with energy intake. The results indicated significant correlation coefficients for both the secretion quantity of allantoin in milk (r = 0.942) and the concentration of allantoin in blood plasma (r = 0.694). Other investigated compounds appeared more suitable for evaluating the mammary gland metabolism (uridine-lactose synthesis, pseudouridine-protein synthesis). In an experiment with 7 male castrated pigmy goats subjected to a four-day fasting period the decrease of plasma allantoin, which was already apparent after 12 hours of fasting, was closely correlated with the increase of plasma free fatty acids.

Drug-induced gout

A number of pharmacological agents can induce hyperuricaemia, and sometimes gout, usually by interfering with the renal tubular excretion of urate but also in some instances by increasing the formation of uric acid. Alcohol is well known to have this property and in recent years diuretic-induced hyperuricaemia has become a global phenomenon. Other drugs which can cause hyperuricaemia are salicylates, pyrazinamide, ethambutol, nicotinic acid, cyclosporin, 2-ethylamino-1,3,4-thiadiazole, fructose and cytotoxic agents. A special type of 'drug-induced gout' can follow the rapid lowering of serum uric acid by allopurinol or uricosuric drugs.

[Effects of purine-rich nutrition on the renal and extrarenal excretion of purine catabolites in Dalmatian dogs]

In eight Dalmatian dogs exogenous effects (dietary purine, xylit infusion) on plasma uric acid were examined and relationships between purine intake and excretion were established. Increasing purine intake resulted in a linear increase in renal excretion of urate (r = 0.952) and a less steep increase of allantoin (r = 0.901). In pairs of two animals with low and high purine intakes the metabolic fluxes in steady state were measured by continuous infusion of (2-14C) urate. The extrarenal excretion rates of urate + allantoin during high-purine and low purine feeding averaged 2.9% and 8.5% of entry rates. The results are discussed in comparison with human data and a remarkably good agreement is observed.

[Effect of purine-rich nutrients on weight gain, catabolites in blood plasma and the uric acid transport of erythrocytes--a model study in dogs]

In a nutritional tolerance study 36 young dogs were fed over 52 weeks high or low purine diets at an average paired feeding intake of 0.6 and 80 mg purine-N/MJ per day. The high purine diet resulted in a significant decrease of growth rate by -23% (Beagles) and -38% (Dalmatians) and of feed efficiency (-29 and -42%). The fasting levels of allantoin, uric acid and uracil in blood plasma were significantly increased. During the experiment a metabolic adaptation to the high purine diet decreased the plasma concentrations of uric acid, uracil and in part of allantoin. The high purine diet effected a significant increase of Km (2.5-fold) and of Vmax (1.6-fold) of uric transport through the erythrocyte membrane. The results documented disadvantageous effects of high purine nutrition during juvenile development.

Quantification and kinetics of purine catabolism in Dalmatian dogs at low and high purine intakes

1. In eight Dalmatian dogs low and high purine intakes resulted in plasma urate levels from 25 to 185 mumol/l. 2. The relationship between purine intake and excretion of uric acid and allantoin per day was described by linear regression equations. 3. The elimination of endogenous purines was 1.8 mmol/day for urate and 1.7 mmol/day for allantoin. Exogenous purines increased renal excretion by 0.57 mmol/mmol. 4. Kinetic measurements with [2(-14)C]uric acid infused continuously into each of two dogs on low and high purine revealed increases of plasma pool (urate + allantoin) of 3.3 fold and entry rate of 4.0 fold. Conversion of urate into allantoin increased from 20 to 36%. 5. Renal elimination of catabolites increased 3.3 fold and exhalation rate of purine-CO2 379 fold. Extra-renal elimination at high purine intake was quantitatively similar to humans and closely related to pool size.

Purine seizure disorders

Developing antiepileptic agents that are specifically tailored to a patient's individual biochemistry has long been a goal of neurology. Three patients who had hyperuricosuria combined with a seizure disorder that failed to respond to traditional anticonvulsants are described. The patients had the best control of their seizure disorder when a specific metabolic drug, allopurinol, was used as an anticonvulsant. All three patients had onset of the seizure disorder at 22 months of age, a finding possibly related to maturation of purine enzymes. Because elevated uric acid levels in the immediate postictal period may occur in seizure patients, the presence of an elevated uric acid clearance in seizure-free periods is needed to consider the diagnosis of an allopurinol-responsive seizure problem in any individual patient. In the two patients past the onset of puberty, lowering (one case) and cessation (other case) of the dose of allopurinol has been possible.

Gout and uric acid nephropathy: some new aspects in diagnosis and treatment

It has been recognized that primary disorders of uric acid metabolism result from impaired renal excretion or increased endogenous production of uric acid. It has also been found that these two mechanisms do not comprise two distinct syndromes, but may each constitute a group of syndromes. Contrary to earlier as well as currently published reports we conclude from our clinical and experimental experience that the fraction of so-called over-producers is less than 1% of all patients with primary hyperuricaemia and gout. A procedure for the diagnosis of uric acid overproduction is suggested. The manifestation of hyperuricaemia and gout mainly depends on renal uric acid clearance and is greatly influenced by dietary habits in most of the patients. An impaired renal uric acid excretion results in an increased intestinal excretion; this partly compensates for the defect. Normalization of serum uric acid should be achieved by dietary regimens with or without additional drug treatment, but not by drug treatment alone. With drug treatment xanthine oxidase inhibitors are preferable to uricosurics; no other xanthine oxidase inhibitor besides Allopurinol has been in clinical trial, however. Due to the enhancement of uric acid clearance with uricosurics, there are groups of patients who should not be treated with these drugs. Fixed combinations of Allopurinol and uricosurics should not be used. Drugs which have uricosuric as well as other pharmacologic properties are under investigation. So far they have not reached general clinical application.