Role of febuxostat in retarding progression of diabetic kidney disease with asymptomatic hyperuricemia: A 6-months open-label, randomized controlled trial

Comparative efficacy and safety of febuxostat and allopurinol in chronic kidney disease stage 3-5 patients with asymptomatic hyperuricemia: a network meta-analysis

OBJECTIVE

This study evaluates and compares the effectiveness and safety of febuxostat and allopurinol in chronic kidney disease (CKD) stages 3-5 patients with asymptomatic hyperuricemia using a network meta-analysis.

METHODS

A systematic review and network meta-analysis were conducted, adhering to PRISMA-NMA guidelines. Searches included PubMed, Embase, Cochrane Library, and Chinese databases up to June 2024. Randomized controlled trials (RCTs) and cohort studies were assessed for methodological rigor using GRADE.

RESULTS

A total of 12 RCTs and 4 cohort studies (n = 2,423 participants) were included. Febuxostat was associated with greater improvements in estimated glomerular filtration rate compared to allopurinol (MD, 4.99 mL/min/1.73 m2; 95%CI -0.65 to 10.78; certainty: low) and placebo (MD, 4.72 mL/min/1.73 m2; 95%CI 0.67 to 8.82; low). Serum uric acid reduction was also more pronounced with febuxostat (MD, -0.61 mg/dL; 95%CI -1.15 to -0.05; moderate). Safety outcomes, including major cardiovascular events and adverse events, showed no significant differences between febuxostat and allopurinol. Subgroup analyses revealed enhanced effectiveness of febuxostat at six months of treatment.

CONCLUSIONS

This analysis provides robust evidence that febuxostat might offers greater improvements in kidney function and uric acid levels compared to allopurinol or placebo in asymptomatic hyperuricemia with CKD stage 3-5 patients, without compromising safety. These findings can guide clinical decision-making and treatment optimization.

Association between urate-lowering therapy and kidney failure in patients with chronic kidney disease

BACKGROUND

Hyperuricemia is a hallmark of gout and a suspected risk factor for the progression of chronic kidney disease (CKD). However, the impact of urate-lowering therapy on CKD progression is subject to debate. The objective of the present study was to describe the prevalence of inappropriate urate-lowering therapy prescriptions and evaluate the association between urate-lowering therapy prescription and the progression of kidney disease in patients with CKD.

METHODS

CKD-REIN is a French, nationwide, prospective cohort of 3,033 nephrology outpatients with CKD (eGFR < 60 mL/min/1.73 m2). Prescriptions of urate-lowering therapy drugs (allopurinol or febuxostat) were recorded prospectively. The appropriateness of each prescription was evaluated according to the patient's kidney function at baseline and during follow-up. Propensity score-matched, cause-specific Cox proportional hazards regression models were used to assess the association between incident urate-lowering therapy use and CKD progression (defined as the initiation of kidney replacement therapy (KRT) but also in other ways).

RESULTS

At baseline, 987 of the 3009 patients included in this study (median age: 69; men: 66%) were receiving urate-lowering therapy; 396 of these 987 patients were receiving an inappropriate prescription with regard to their kidney function. During a 5-year follow-up period, 70% of the 396 urate-lowering therapy prescriptions remained inappropriate. In the propensity score-matched cohort (n = 674), 136 patients started KRT. Compared with non- urate-lowering therapy use, urate-lowering therapy use was not significantly associated with a slowing in CKD progression, regardless of the definition used (HRKRT 0.89, 95% CI 0.67-1.20).

CONCLUSIONS

Our real-world data emphasized the lack of reassessment of urate-lowering therapy prescriptions in patients with CKD. Urate-lowering therapy was not associated with a slowing of CKD progression.

Reno-protective effects of xanthine oxidase inhibitors in patients with type 2 diabetes and chronic kidney disease: a systematic review and meta-analysis

BACKGROUND

The effect of lowering uric acid levels on renal function in patients with diabetic kidney disease remains unclear. Previous randomized controlled trials (RCTs) have reported conflicting results regarding the effects of xanthine oxidase inhibitors on renal function. This study aimed to examine the renoprotective effects of xanthine oxidase inhibitors (febuxostat and topiroxostat) in patients with diabetic kidney disease.

METHODS

Relevant RCTs were searched using PubMed, Embase, and Cochrane Central databases. Ultimately, five RCTs were included in the meta-analysis. The assessed renal endpoints included changes in the estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio. The meta-analysis was conducted using Review Manager version 5.4. Standardized mean differences (SMDs) and 95% confidence intervals (CIs) were calculated for changes in renal endpoints between the groups after the study period. A subgroup analysis was conducted based on the type of intervention, results of the risk of bias assessment, and baseline renal function.

RESULTS

Although the use of febuxostat or topiroxostat did not induce a significant change in eGFR compared with the placebo, it showed a tendency to delay renal function decline (SMD = 0.32, 95% CI = [- 0.00; 0.64]). There was no significant difference in albuminuria between the two groups (SMD = 0.26, 95% CI = [- 0.10; 0.62]).

CONCLUSIONS

This study suggests the potential of febuxostat or topiroxostat to delay renal function decline in patients with diabetes and underlying renal impairment, that needs to be confirmed in further studies.

TRIAL REGISTRATION

INPLASY registration number 202450024.

The link between hyperuricemia and diabetes: insights from a quantitative analysis of scientific literature

Background

Hyperuricemia (HUA) is a significant public health issue, ranking second only to diabetes in prevalence. While existing research demonstrates a robust correlation between these two conditions, the precise etiological mechanisms remain inadequately elucidated. This study utilized scientometric analysis to investigate the global association between HUA and diabetes.

Methods

Data on HUA and diabetes were retrieved from the Web of Science Core Collection database, encompassing the period from its inception until September 30, 2024. Collaboration networks were examined using VOSviewer, cluster analysis was executed with CiteSpace, and systematic mapping was conducted using Bibliometrix.

Results

By September 30, 2024, 1,464 studies indicated a consistent yearly increase in publications connecting HUA and diabetes despite some fluctuations. The lead authors were Richard J. Johnson, Miguel A. Lanaspa, and Masanari Kuwabara, with most contributors from China, the United States, and Japan. Key institutions include China Medical University, Shanghai Jiao Tong University, and Capital Medical University. The most published journal was Nutrition, Metabolism and Cardiovascular Diseases (CVDs), whereas the most cited journal was Diabetes Care. The reference network from 1987 to September 30, 2024, identified 19 clusters highlighting key research areas in HUA and diabetes, such as metabolic syndrome, uropathology, chronic kidney disease (CKD), and CVD. Exploring pathological mechanisms and pharmacological interventions linked to diabetes concomitant with HUA has emerged as a focal point of research and a burgeoning trend within the field.

Conclusion

This study is the first scientometric analysis to synthesize research trends on HUA and diabetes, revealing molecular mechanisms and treatment strategies and providing theoretical insights for future clinical use.

Cardiovascular outcomes of urate-lowering therapies in patients with gout or hyperuricemia: a network meta-analysis

BACKGROUND

To evaluate the comparative cardiovascular safety of urate-lowering therapies (ULTs) in patients with gout or hyperuricemia.

RESEARCH DESIGN AND METHODS

Randomized controlled trials (RCTs) for ULTs with reported cardiovascular outcomes were included. Pairwise and network random-effect meta-analyses were performed to obtain the odds ratios (ORs) with 95% confidence intervals (CIs). The surface under the cumulative ranking curve (SUCRA) was employed to assess and rank the cardiovascular safety of ULTs.

RESULTS

A total of 3,663 literature were retrieved, of which 26 RCTs involving 25,329 patients were finally included. Pairwise and network meta-analyses showed that allopurinol demonstrated a significant reduction in arrhythmia compared with febuxostat (for pairwise meta-analysis, OR = 0.69, 95%CI 0.49 to 0.97; for network meta-analysis, OR = 0.71, 95%CI 0.51 to 0.99). Nevertheless, there was no statistically significant difference observed in other outcomes between different ULTs or between ULTs and placebo (p > 0.05). According to the SUCRA, febuxostat and pegloticase, had the highest probability of mitigating the occurrence of major adverse cardiovascular events (MACEs) and all-cause mortality respectively.

CONCLUSIONS

Overall, ULTs showed relatively good cardiovascular safety in patients with gout or hyperuricemia. However, febuxostat has a higher risk of arrhythmia compared with allopurinol. Further studies are needed to confirm our findings.

Comparative Cardiovascular Risks of Febuxostat and Allopurinol in Patients with Diabetes Mellitus and Chronic Kidney Disease

BACKGROUND Hyperuricemia, which is common in chronic kidney disease and diabetes mellitus patients, raises health concerns. Febuxostat, a first-line urate-lowering agent, prompts cardiovascular risk questions, especially in high-risk patients. This study compared the effects of febuxostat and allopurinol on cardiovascular risk in diabetes mellitus and chronic kidney disease patients. MATERIAL AND METHODS This retrospective observational cohort study, conducted using Taiwan's National Health Insurance Research Database, focused on patients diagnosed with chronic kidney disease and diabetes between January 2012 and December 2017. The study population was divided into 2 groups: allopurinol users (n=12 901) and febuxostat users (n=2997). We performed 1: 1 propensity score matching, resulting in subgroups of 2997 patients each. The primary outcomes were assessed using a competing risk model, estimating hazard ratios (HR) for long-term outcomes, including the risks of all-cause hospitalization, hospitalization for heart failure, and hospitalization for cardiovascular interventions. RESULTS Febuxostat users, compared to allopurinol users, had higher all-cause hospitalization (HR: 1.33; 95% confidence interval [CI]: 1.25 to 1.42; P<.001), hospitalization for heart failure (HR: 1.62; 95% CI: 1.43 to 1.83; P<.001), and hospitalization for cardiovascular interventions (HR: 1.51; 95% CI: 1.32 to 1.74; P<.001). Moreover, the adverse effects of febuxostat on cardiac health were consistent across most subgroups. CONCLUSIONS Use of febuxostat in patients with diabetes mellitus and chronic kidney disease is associated with higher cardiovascular risks compared to allopurinol. Prudent evaluation is essential when recommending febuxostat for this at-risk group.

Cardiovascular Safety of Febuxostat in Patients With Gout or Hyperuricemia: A Systematic Review of Randomized Controlled Trials

INTRODUCTION

To this date, a causal relationship between febuxostat and cardiovascular disease remains controversial as comparison between trials can be challenging and may lead to misleading conclusions, especially when facing heterogeneous cardiovascular outcomes. We aimed to compare the cardiovascular outcomes in the most pertinent trials of febuxostat compared with controls.

METHODS

We searched electronic databases using a PICOS-style approach search strategy of randomized controlled trials (RCTs) on cardiovascular outcomes of febuxostat in patients with gout or hyperuricemia. We conducted a quality and risk of bias assessment of the included clinical trials. The definition of major adverse cardiovascular event as well as all reported cardiovascular outcomes were retrieved from every involved trial.

RESULTS

Of the 1173 records identified from all sources, 20 RCTs were included in the analysis. The mean duration of follow-up was 69.7 ± 81.5 weeks, and febuxostat dose ranged from 10 to 240 mg with 80 mg being the most commonly used dosage. Overall, the quality of evidence deriving from all RCTs showed concerns in most studies (65%). Major adverse cardiovascular event was defined in 7 of the 20 RCTs (35%), and cardiovascular outcome reporting was very heterogeneous. Overall, the data of cardiovascular safety of febuxostat were reassuring.

CONCLUSIONS

Our systematic review showed high level of concerns in quality assessment domains as well heterogeneous cardiovascular outcomes across included studies. Cardiovascular outcomes in the majority of White males with gout treated with febuxostat were reassuring when compared with allopurinol. Further studies are needed to draw conclusions in patients with severe cardiovascular disease.

Effects of uric acid-lowering therapy (ULT) on renal outcomes in CKD patients with asymptomatic hyperuricemia: a systematic review and meta-analysis

BACKGROUND

It is well known that asymptomatic hyperuricemia and gout play an important role in patients with chronic kidney disease (CKD). However, the effect of uric acid-lowering therapy (ULT) on the prognosis of CKD patients with asymptomatic hyperuricemia remains controversial. Therefore, we aim to investigate the influence of ULT on renal outcomes in these patients.

METHODS

Comprehensive searches were conducted in PubMed, EMBASE, China National Knowledge Internet (CNKI), and the Cochrane Library, up until January 2024. We included randomized controlled trials (RCTs) that evaluated the effects of ULT on renal outcomes in CKD patients with asymptomatic hyperuricemia.

RESULTS

A total of 17 studies were included in the meta-analysis. Compared with placebo or no treatment, ULT preserved the loss of estimated glomerular filtrating rate (eGFR) (Weighted mean difference [WMD] and its 95% confidence intercal(CI): 2.07 [0.15,3.98] mL/min/1.73m2) at long-term subgroup. At the same time, short-term subgroup also proved the preserved loss of eGFR (WMD 5.74[2.09, 9.39] mL/min/1.73m2). Compared with placebo or no treatment, ULT also reduced the increase in serum creatinine (Scr) at short-term (WMD -44.48[-84.03,-4.92]μmol/L) subgroup and long-term (WMD -46.13[-65.64,-26.62]μmol/L) subgroup. ULT was associated with lower incidence of the events of doubling of Scr without dialysis (relative risk (RR) 0.32 [0.21, 0.49], p < 0.001). However, no difference was found for lower incidence of acute kidney injury (AKI) (p = 0.943).

CONCLUSIONS

According to our study, ULT is beneficial for slowing CKD progression both in short to long-term follow-ups. Additionally, in patients younger than 60 years old, the protective effect of ULT on renal outcome is more pronounced. However, it showed no significant difference in the incidence of AKI. These findings underscore the importance of considering ULT in clinical strategies for CKD patients with asymptomatic hyperuricemia.

Effects of febuxostat on delaying chronic kidney disease progression: a randomized trial in China

BACKGROUND

A few studies have tested febuxostat for its usefulness in delaying chronic kidney disease (CKD) progression by treating hyperuricemia and results were controversial. Thus, we attempted to conduct a randomized controlled study using the Chinese population with advanced grade of CKD.

METHODS

One hundred CKD patients in stages 3 and 4 with asymptomatic hyperuricemia from seven medical centers were included in this prospective randomized controlled study and assigned to the control and febuxostat group, the latter of which received febuxostat to titrate to achieve serum uric acid (SUA) < 6 mg/dL. The observation period was 12 months. The primary outcomes included the event of estimated glomerular filtration rate (eGFR) decline ≥ 30% or 50% from baseline at 12 months, dialysis and death from CKD; secondary outcome was the change in eGFR. Safety analysis was also performed.

RESULTS

Forty-seven patients and 45 patients in the febuxostat and control groups, respectively completed the study. Seven of 47 (14.9%) participants reached 30% decline in eGFR in the febuxostat group, while 1 (2.1%) and 2 (4.3%) patients reached 50% decline in eGFR or dialysis. Thirteen (28.9%), 10 (22.2%) and 3 (6.7%) of 45 patients reached primary kidney outcomes separately in the control group. The change in eGFR after 12 months from baseline in the febuxostat group was 0.50 mL/min/1.73 m², which was significantly higher than that in the control group - 4.46 mL/min/1.73 m² (p = 0.006). Adverse events did not differ between two groups.

CONCLUSIONS

Febuxostat effectively slowed eGFR decline in patients with CKD stages 3 and 4 and asymptomatic hyperuricemia.

Caring for Australians and New Zealanders With Kidney Impairment Guidelines: Rapid Development of Urate Lowering Therapy Guidelines for People With CKD

Introduction

The slow transformation of new research findings into clinical guidelines is a barrier to providing evidence-based care. The Caring for Australians and New Zealanders with Kidney Impairment (CARI) guidelines are developing models to improve guideline production, one methodology involves more functional concordance between trial groups, such as the Australian Kidney Trials Network (AKTN) and CARI. The objective of this project was to rapidly produce an evidence-based guideline on urate-lowering therapy in patients with chronic kidney disease (CKD), in response to new clinical trial publications on the topic by the AKTN.

Methods

To produce a guideline as rapidly as possible, an existing systematic review was utilized as the evidence base, and then updated with the inclusion of clinical trials that had been published subsequently. A Work Group was convened to review the evidence and compose an appropriate guideline using CARI/GRADE methodology. The group met 3 times over 45 days to formulate the guideline.

Results

The result was a strong recommendation against the use urate-lowering therapies in individuals with CKD (not receiving dialysis) and asymptomatic hyperuricemia. The process of identifying an appropriate existing systematic review, updating the literature search, and synthesizing the evidence, was done by 2 individuals over 15 days. The Work Group was formulated and composed the guideline over 45 days. In all, a new guideline incorporating the most up-to-date evidence was formulated in 60 days.

Conclusion

This method of guideline development represents a potentially new way of releasing guidelines that encapsulates all available evidence in a time-efficient manner.

Febuxostat Therapy for Patients with Gout and Stage 2-4 CKD: a Retrospective Study

Introduction

The aim of this study is to explore the efficacy and renal safety of febuxostat in gout and stage 2–4 chronic kidney disease (CKD) and factors that correlated with target serum urate (SU).

Methods

A single-center retrospective study including male patients with gout and CKD was conducted. SU, the rate of SU < 360 µmol/L (RAT), and renal safety were analyzed in subjects who received febuxostat over 44 weeks. Factors that correlated with target SU were also explored.

Results

Between January 2017 and March 2021, 102 patients (stage 2 CKD: n = 27; stage 3 CKD: n = 70; stage 4 CKD: n = 5) were enrolled. The SU level reduced significantly over 44 weeks (600.76 ± 95.42 versus 405.52 ± 111.93 µmol/L; P < 0.05), and RAT increased to 39.20%. The overall estimated glomerular filtration rate (eGFR) level improved over 44 weeks (52.05 ± 11.68 versus 55.46 ± 14.49 mL/min/1.73 cm², P < 0.05). An obvious improvement of eGFR was observed in stage 3 CKD, in patients with ≤ 1 risk factor (hypertension, diabetic mellitus, hyperlipidemia, or usage of non-steroidal anti-inflammatory drugs), and in patients with terminal SU < 360 µmol/L (P < 0.05). Logistic regression analysis indicated that baseline SU level and body weight were correlated with RAT. Further analysis revealed that patients with SU < 600 μmol/L and body weight ≤ 70 kg reached higher RAT (56.7%).

Conclusions

Febuxostat demonstrated efficacy and renal safety in patients with gout and CKD in clinical practice. Achieving the target SU could obviously improve renal function. Baseline SU level and body weight could affect the achievement of target SU.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-022-00480-7.

Efficacy and safety of urate-lowering agents in asymptomatic hyperuricemia: systematic review and network meta-analysis of randomized controlled trials

BACKGROUND

Asymptomatic hyperuricemia was found to be associated with increased cardiovascular disease risk but the potential benefits of urate-lowering therapy (ULT) remain controversial. We conducted a systematic review and network meta-analysis (NMA) with frequentist model to estimate the efficacy and safety of ULT in asymptomatic hyperuricemia.

METHODS

MEDLINE, Embase, and Scopus were searched without language restrictions. Randomized controlled trials (RCT) of adults with asymptomatic hyperuricemia were eligible if they compared any pair of ULTs (i.e., allopurinol, febuxostat, probenecid, benzbromarone, sulfinpyrazone, rasburicase, lesinurad, and topiroxostat) and placebo or no ULT, and had outcomes of interest, including composite renal events, major adverse cardiovascular events, serum urate levels, estimated glomerular filtration rate (eGFR), systolic blood pressure, and adverse events.

RESULTS

NMA with frequentist approach was applied to estimate relative treatment effects, i.e., risk ratio (RR) and mean difference (MD). A total of 23 RCTs were eligible. NMA identified beneficial effects of ULT on composite renal events and eGFR but not for other outcomes. Allopurinol and febuxostat had significantly lower composite renal events than placebo (RR 0.39, 95% confidence interval [CI] 0.23 to 0.66, and RR 0.68, 95% CI 0.46 to 0.99, respectively). Both treatments also resulted in significantly higher eGFR than placebo (MD 3.69 ml/min/1.73 m², 95% CI 1.31 to 6.08, and MD 2.89 ml/min/1.73 m², 95% CI 0.69 to 5.09, respectively). No evidence of inconsistency was identified.

CONCLUSIONS

Evidence suggests that allopurinol and febuxostat are the ULTs of choice in reducing composite renal events and improving renal function.

TRIAL REGISTRATION

This study was registered with PROSPERO: CRD42019145908. The date of the first registration was 12^th November 2019.

Hyperuricemia and diabetes mellitus when occurred together have higher risks than alone on all-cause mortality and end-stage renal disease in patients with chronic kidney disease

Introduction

Hyperuricemia and diabetes mellitus (DM) are associated with increased mortality risk in patients with chronic kidney disease (CKD). Here we aimed to evaluate the independent and joint risks of these two conditions on mortality and end stage kidney disease (ESKD) in CKD-patients.

Methods

This retrospective cohort study enrolled 4380 outpatients (with CKD stage 3–5) with mortality and ESKD linkage during a 7-year period (from 2007 to 2013). All-causes mortality and ESKD risks were analyzed by multivariable-adjusted Cox proportional hazards models (adjusted for age, sex, smoke, previous coronary arterial disease, blood pressure, and medications for hyperlipidemia, hyperuricemia and renin–angiotensin system inhibitors).

Results

Overall, 40.5% of participants had DM and 66.4% had hyperuricemia. In total, 356 deaths and 932 ESKD events occurred during the 7 years follow-up. With the multivariate analysis, increased risks for all-cause mortality were: hyperuricemia alone, HR = 1.48 (1–2.19); DM alone, and HR = 1.52 (1.02–2.46); DM and hyperuricemia together, HR = 2.12 (1.41–3.19). Similar risks for ESKD were: hyperuricemia alone, HR = 1.34 (1.03–1.73); DM alone, HR = 1.59 (1.15–2.2); DM and hyperuricemia together, HR = 2.46 (1.87–3.22).

Conclusions

DM and hyperuricemia are strongly associated with higher all-cause mortality and ESKD risk in patients with CKD stage 3–5. Hyperuricemia is similar to DM in terms of risk for all-cause mortality and ESKD. DM and hyperuricemia when occurred together further increase both risks of all-cause mortality and ESKD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02755-1.

Effectiveness of Urate-Lowering Therapy for Renal Function in Patients With Chronic Kidney Disease: A Meta-Analysis of Randomized Clinical Trials

Background and Objective: Hyperuricemia is closely related to chronic kidney disease (CKD). The effects of urate-lowering therapy (ULT) on renal outcomes are uncertain, and whether it is warranted in CKD patients is currently unclear. The aim of our meta-analysis of randomized clinical trials (RCTs) was to assess the effectiveness and safety of ULT for improving kidney function in patients with CKD.

Methods: RCTs were retrieved from the PubMed, Embase, MEDLINE and Cochrane Central Register of Controlled Trials databases. The meta-analysis was performed using Review Manager and Stata/SE software. The outcomes were changes in renal function and serum uric acid (SUA), serum creatinine, and adverse events.

Results: Twelve RCTs with 1,469 participants were included in the meta-analysis. ULT was found to effectively lower SUA (standard mean difference (SMD): -2.70; 95% confidence interval (CI): -3.71, -1.69) but the renoprotective effects were not superior to those of control therapy (placebo or usual therapy), which were stable in the subgroup analyses and sensitivity analyses. Regarding adverse events, their risks did not increase in the ULT group compared with the control group and were stable in the sensitivity analyses.

Conclusion: The findings of our meta-analysis suggested that ULT can effectively lower SUA, but there is insufficient evidence to support the renoprotective effects of ULT in CKD patients. In addition, ULT is safe for patients with CKD.

Systematic Review Registration:https://clinicaltrials.gov/, identifier PROSPERO (CRD42020200550).

Effect of Urate-Lowering Therapy on the Progression of Kidney Function in Patients With Asymptomatic Hyperuricemia: A Systematic Review and Meta-Analysis

Background: Hyperuricemia is involved in the risk of chronic kidney disease (CKD). However, whether urate-lowering therapy (ULT) can influence the progression of kidney function in patients with asymptomatic hyperuricemia is still controversial. We conducted a systematic review and meta-analysis to evaluate the effect of ULT on the progression of kidney function in asymptomatic hyperuricemia patients.

Methods: The MEDLINE, EMBASE and Cochrane databases were searched without language, national or ethnic restrictions for randomized controlled trials published prior to November 30, 2020, that compared ULT with controlled therapy in patients with asymptomatic hyperuricemia.

Results: Eleven studies were included for qualitative synthesis. ULT did not ameliorate eGFR slopes (WMD 0.36 ml/min/1.73 m² per year, 95% CI: −0.31, 1.04), or lead to reductions in kidney events (RR 1.26; 95% CI: 0.80, 2.00) or all-cause mortality (RR 1.00; 95% CI: 0.65, 1.55), although ULT resulted in a decrease in serum uric acid levels (WMD −2.73 mg/dl; 95% CI: −3.18, −2.28) and lowered the incidence of gout episodes (0.9 vs 2.7%, RR 0.38; 95% CI: 0.17, 0.86).

Conclusion: In patients with asymptomatic hyperuricemia, ULT did not decay the progression of kidney function. Long-term and larger sample studies are needed to verify the results.

Systematic Review Registration: [www.crd.york.ac.uk/PROSPERO/#recordDetails], identifier [CRD42020204482].

A Non-purine Xanthine Oxidoreductase Inhibitor Reduces Albuminuria in Patients with DKD: A Randomized Controlled Trial

Background

Diabetic kidney disease (DKD) is characterized by albuminuria and reduced renal function. Whether xanthine oxidoreductase inhibitors (XORIs) have a renoprotective effect in DKD patients with type 2 diabetes remains controversial. We conducted a proof-of-concept study to investigate the renal effects of a novel XORI, TMX-049, in patients with DKD and type 2 diabetes.

Methods

This is a multicenter, 12-week, randomized, double-blind, placebo-controlled phase 2a trial conducted at 49 centers across the United States between April 2018 and June 2019. In total, 130 patients with type 2 diabetes, urine albumin-creatinine ratio (UACR) 200 - 3000 mg/g, eGFR ≥30 ml/min per 1.73 m2, and serum uric acid (sUA) 4 - 10 mg/dl were randomized 1:1:1 to TMX-049 200 mg (n=44) or 40 mg (n=44), or placebo (n=42). The primary end point was change in log-transformed UACR at week 12 from baseline. The secondary end points included changes in UACR, eGFR, and sUA from baseline.

Results

The least squares mean differences for changes in log-transformed UACR from baseline to week 12 compared with placebo were -0.43 (95% confidence interval [95% CI], -0.82 to -0.04, P=0.03) for TMX-049 200 mg and -0.05 (95% CI, -0.44 to 0.34, P=0.80) for 40 mg; a 35% reduction in UACR was observed with TMX-049 200 mg (ratio versus placebo, 0.65; 95% CI, 0.44 to 0.96) but not 40 mg (0.95; 95% CI, 0.64 to 1.41). Throughout the treatment period, marked reductions in sUA levels but no changes in eGFR were observed with both TMX-049 doses. TMX-049 was generally well tolerated, although two patients with TMX-049 200 mg developed gout.

Conclusions

TMX-049 200 mg reduced albuminuria at 12 weeks in patients with DKD and type 2 diabetes. TMX-049 may exert a renoprotective effect independent of its sUA-lowering effect.

Effectiveness of Drug Treatments for Lowering Uric Acid on Renal Function in Patients With Chronic Kidney Disease and Hyperuricemia: A Network Meta-Analysis of Randomized Controlled Trials

Background: Hyperuricemia is very common in patients with chronic kidney disease (CKD); the role of hyperuricemia in the occurrence and progression of kidney disease remains an interesting and unresolved issue for nephrologists, and whether urate-lowering therapy (ULT) is warranted in CKD patients is still in controversy. To summarize and compare the clinical outcomes and adverse events (AEs) of three common ULT drugs, we performed a systematic review and network meta-analysis of randomized clinical trials (RCTs). Method: PubMed, MEDLINE, Clinical Trials.gov, EMBASE, and the Cochrane Central Register of Controlled Trials electronic databases were searched. The network meta-analysis was performed using the "gemtc 0.8-7" and its dependent packages in R software. The primary outcome was the change of renal function and uric acid; creatinine, proteinuria, blood pressure, and adverse events were assessed as the secondary outcomes. Results: 16 RCTs involving 1,943 patients were included in the final network analysis. Febuxostat, allopurinol, and benzbromarone were not found to exert superior effects over placebo upon renoprotective effect. With respect to lowering urate, the three drugs showed to be statistically superior to placebo, while febuxostat could better lower urate than allopurinol (MD: -1.547; 95% CrI: -2.473 to -0.626). It is also indicated that febuxostat was superior to placebo at controlling blood pressure, while no differences were observed when allopurinol and benzbromarone were compared to placebo. These results are stable in subgroup analysis. Conclusion: There is insufficient evidence to support the renoprotective effects of the three urate-lowering agents in CKD patients with hyperuricemia; febuxostat shows a tendency to be superior to allopurinol on lowering the decline of eGFR and increment of proteinturia, but the difference does not reach a statistical significance. Regarding its urate-lowering effect, febuxostat appears to be a satisfactory alternative to allopurinol and benzbromarone, and can control blood pressure better.

Oxidative Stress and Inflammation in Renal and Cardiovascular Complications of Diabetes

Simple Summary

The progressive nature of type 2 diabetes mellitus (T2DM) leads to micro- and macro-vascular complications, including renal and cardiovascular disease. These alone, or in combination, are a major cause of premature morbidity and mortality in diabetic patients. Despite advances in glucose lowering treatments, these diabetic complications are still inadequately prevented or reversed. This ongoing cardiovascular–renal burden in diabetes poses a heavy cost on the health care system. Therefore, there is an urgent need to develop more effective treatments. In this review, we discuss how oxidative stress and inflammation induce and perpetuate the renal and cardiovascular complications of diabetes. It is particularly important to understand these driving mechanisms in order to elucidate pharmacological targets and mechanism-based future drug therapies.

Abstract

Oxidative stress and inflammation are considered major drivers in the pathogenesis of diabetic complications, including renal and cardiovascular disease. A symbiotic relationship also appears to exist between oxidative stress and inflammation. Several emerging therapies target these crucial pathways, to alleviate the burden of the aforementioned diseases. Oxidative stress refers to an imbalance between reactive oxygen species (ROS) and antioxidant defenses, a pathological state which not only leads to direct cellular damage but also an inflammatory cascade that further perpetuates tissue injury. Emerging therapeutic strategies tackle these pathways in a variety of ways, from increasing antioxidant defenses (antioxidants and Nrf2 activators) to reducing ROS production (NADPH oxidase inhibitors and XO inhibitors) or inhibiting the associated inflammatory pathways (NLRP3 inflammasome inhibitors, lipoxins, GLP-1 receptor agonists, and AT-1 receptor antagonists). This review summarizes the mechanisms by which oxidative stress and inflammation contribute to and perpetuate diabetes associated renal and cardiovascular disease along with the therapeutic strategies which target these pathways to provide reno and cardiovascular protection in the setting of diabetes.

Effect of Urate-Lowering Therapy on Cardiovascular and Kidney Outcomes: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Several clinical practice guidelines noted the potential benefits of urate-lowering therapy on cardiovascular disease and CKD progression; however, the effect of this regimen remains uncertain. In this systematic review, we aimed to evaluate the efficacy of urate-lowering therapy on major adverse cardiovascular events, all-cause mortality, kidney failure events, BP, and GFR.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We systematically searched MEDLINE, Embase, and the Cochrane databases for trials published through July 2020. We included prospective, randomized, controlled trials assessing the effects of urate-lowering therapy for at least 6 months on cardiovascular or kidney outcomes. Relevant information was extracted into a spreadsheet by two authors independently. Treatment effects were summarized using random effects meta-analysis.

RESULTS

We identified 28 trials including a total of 6458 participants with 506 major adverse cardiovascular events and 266 kidney failure events. Overall urate-lowering therapy did not show benefits on major adverse cardiovascular events (risk ratio, 0.93; 95% confidence interval, 0.74 to 1.18) and all-cause mortality (risk ratio, 1.04; 95% confidence interval, 0.78 to 1.39) or kidney failure (risk ratio, 0.97; 95% confidence interval, 0.61 to 1.54). Nevertheless, urate-lowering therapy attenuated the decline in the slope of GFR (weighted mean difference, 1.18 ml/min per 1.73 m² per year; 95% confidence interval, 0.44 to 1.91) and lowered the mean BP (systolic BP: weighted mean difference, -3.45 mm Hg; 95% confidence interval, -6.10 to -0.80; diastolic BP: weighted mean difference, -2.02 mm Hg; 95% confidence interval, -3.25 to -0.78). There was no significant difference (risk ratio, 1.01; 95% confidence interval, 0.94 to 1.08) in the risk of adverse events between the participants receiving urate-lowering therapy and the control group.

CONCLUSIONS

Urate-lowering therapy did not produce benefits on the clinical outcomes, including major adverse cardiovascular events, all-cause mortality, and kidney failure. Thus, there is insufficient evidence to support urate lowering in patients to improve kidney and cardiovascular outcomes.

Effects of Febuxostat on Mortality and Cardiovascular Outcomes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objective

To investigate the association between using febuxostat and cardiovascular events.

Methods

Systematic search of randomized controlled trials was performed using PubMed/MEDLINE, Cochrane review, and EMBASE databases through April 17, 2019. Meta-analysis was performed using random effect model and estimates were reported as risk difference (RD) with 95% CIs. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. The main outcomes of interest were cardiovascular mortality and all-cause mortality.

Results

A total of 15 randomized controlled trials (16,070 participants) were included. The mean ± SD age was 58.1±11.7 years. At the median follow-up of 6.4 months, use of febuxostat was not associated with statistically significant risk of cardiovascular mortality (RD, 0.12%; 95% CI, -0.25% to 0.49%; I²=48%; low certainty evidence), all-cause mortality (RD, 0.20%; 95% CI, -0.28% to 0.68%; I² =60%; very low certainty evidence), major adverse cardiovascular events (RD, 0.40%; 95% CI, -0.34% to 1.13%; I²=26%; low certainty evidence), myocardial infarction (RD, -0.06%; 95% CI, -0.29% to 0.17%; I² =0%; moderate certainty evidence), stroke (RD, 0.10%; 95% CI, -0.15% to 0.35%; I²=0%; moderate certainty evidence), or new-onset hypertension (RD, 1.58%; 95% CI, -0.63% to 3.78%; I²=58%; very low certainty evidence). These findings were consistent in patients with existing cardiovascular disease.

Conclusion

This meta-analysis suggested that use of febuxostat was not associated with higher risk of mortality or adverse cardiovascular outcomes in patients with gout and hyperuricemia. The results were limited by low to moderate certainty of evidence.

Uric acid and inflammation in kidney disease

Asymptomatic hyperuricemia is frequently observed in patients with kidney disease. Although a substantial number of epidemiologic studies have suggested that an elevated uric acid level plays a causative role in the development and progression of kidney disease, whether hyperuricemia is simply a result of decreased renal excretion of uric acid or is a contributor to kidney disease remains a matter of debate. Over the last two decades, multiple experimental studies have expanded the knowledge of the biological effects of uric acid beyond its role in gout. In particular, uric acid induces immune system activation and alters the characteristics of resident kidney cells, such as tubular epithelial cells, endothelial cells, and vascular smooth muscle cells, toward a proinflammatory and profibrotic state. These findings have led to an increased awareness of uric acid as a potential and modifiable risk factor in kidney disease. Here, we discuss the effects of uric acid on the immune system and subsequently review the effects of uric acid on the kidneys mainly in the context of inflammation.

Xanthine Oxidase Inhibitor Febuxostat Exerts an Anti-Inflammatory Action and Protects against Diabetic Nephropathy Development in KK-Ay Obese Diabetic Mice

Hyperuricemia has been recognized as a risk factor for insulin resistance as well as one of the factors leading to diabetic kidney disease (DKD). Since DKD is the most common cause of end-stage renal disease, we investigated whether febuxostat, a xanthine oxidase (XO) inhibitor, exerts a protective effect against the development of DKD. We used KK-Ay mice, an established obese diabetic rodent model. Eight-week-old KK-Ay mice were provided drinking water with or without febuxostat (15 μg/mL) for 12 weeks and then subjected to experimentation. Urine albumin secretion and degrees of glomerular injury judged by microscopic observations were markedly higher in KK-Ay than in control lean mice. These elevations were significantly normalized by febuxostat treatment. On the other hand, body weights and high serum glucose concentrations and glycated albumin levels of KK-Ay mice were not affected by febuxostat treatment, despite glucose tolerance and insulin tolerance tests having revealed febuxostat significantly improved insulin sensitivity and glucose tolerance. Interestingly, the IL-1β, IL-6, MCP-1, and ICAM-1 mRNA levels, which were increased in KK-Ay mouse kidneys as compared with normal controls, were suppressed by febuxostat administration. These data indicate a protective effect of XO inhibitors against the development of DKD, and the underlying mechanism likely involves inflammation suppression which is independent of hyperglycemia amelioration.