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Yip RM, Cheung TT, So H, Chan JP, Ho CT, Tsang HH, Yu CK, Wong PC. The Hong Kong Society of Rheumatology consensus recommendations for the management of gout. Clin Rheumatol 2023:10.1007/s10067-023-06578-9. [PMID: 37014501 DOI: 10.1007/s10067-023-06578-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 02/09/2023] [Accepted: 03/12/2023] [Indexed: 04/05/2023]
Abstract
Gout is one of the most common noncommunicable diseases in Hong Kong. Although effective treatment options are readily available, the management of gout in Hong Kong remains suboptimal. Like other countries, the treatment goal in Hong Kong usually focuses on relieving symptoms of gout but not treating the serum urate level to target. As a result, patients with gout continue to suffer from the debilitating arthritis, as well as the renal, metabolic, and cardiovascular complications associated with gout. The Hong Kong Society of Rheumatology spearheaded the development of these consensus recommendations through a Delphi exercise that involved rheumatologists, primary care physicians, and other specialists in Hong Kong. Recommendations on acute gout management, gout prophylaxis, treatment of hyperuricemia and its precautions, co-administration of non-gout medications with urate-lowering therapy, and lifestyle advice have been included. This paper serves as a reference guide to all healthcare providers who see patients who are at risk and are known to have this chronic but treatable condition.
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Affiliation(s)
- Ronald Ml Yip
- Tung Wah Group of Hospitals Integrated Diagnostic and Medical Centre, Kwong Wah Hospital, 25, Waterloo Road, Kowloon, Hong Kong.
| | - Tommy T Cheung
- Rheumatology Centre, Department of Medicine, Hong Kong Sanatorium & Hospital, Happy Valley, Hong Kong
| | - Ho So
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong
| | - Julia Ps Chan
- Rheumatology Centre, Department of Medicine, Hong Kong Sanatorium & Hospital, Happy Valley, Hong Kong
| | - Carmen Tk Ho
- Division of Rheumatology and Clinical Immunology, Queen Mary Hospital, Pok Fu Lam, Hong Kong
| | - Helen Hl Tsang
- Division of Rheumatology and Clinical Immunology, Queen Mary Hospital, Pok Fu Lam, Hong Kong
| | - Carrel Kl Yu
- Hong Kong Autoimmune and Rheumatic Diseases Centre, Central, Hong Kong
| | - Priscilla Ch Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong
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Johansson S, Han D, Hunt T, Björck K, Florica D, Gillen M, Hall J, Erlandsson F. Pharmacokinetics, pharmacodynamics, and safety of verinurad with and without allopurinol in healthy Asian, Chinese, and non-Asian participants. Pharmacol Res Perspect 2022; 10:e00929. [PMID: 35593744 PMCID: PMC9121888 DOI: 10.1002/prp2.929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 11/10/2021] [Accepted: 12/21/2021] [Indexed: 11/06/2022] Open
Abstract
Verinurad is a selective inhibitor of uric acid transporter 1 (URAT1). Here, we assessed the safety, pharmacokinetics, and pharmacodynamics of verinurad + allopurinol and verinurad monotherapy in healthy participants. Studies 1 (NCT03836599) and 2 (NCT02608710) were randomized Phase 1 studies. In Study 1, 12 healthy Asian participants received 24 mg verinurad + 300 mg allopurinol or placebo, and 9 healthy Chinese participants received 12 mg verinurad + 300 mg allopurinol. In Study 2, 24 healthy non-Asian male participants received 12 mg verinurad. Safety analyses included assessment of adverse events (AEs). Pharmacokinetic parameters included maximum concentration (Cmax ) and area under plasma concentration-time curve (AUC) over 24 h (AUCτ ). Pharmacodynamic parameters included percentage change from baseline (day -1) in serum uric acid (sUA) and urinary uric acid (uUA). There were no serious AEs or deaths in either study. In Study 1, steady-state geometric mean (gCV%) Cmax and AUCτ values of verinurad after 7 days' dosing were 73.6 (29.0) ng/mL and 478 (18.4) ng·h/mL, respectively, in healthy Asian participants, and 42.0 (40.1) ng/mL and 264 (36.1) ng·h/mL, respectively, in healthy Chinese participants; in Study 2, gCV% values were 36.3 (36.5) ng/mL and 271 (31.0) ng·h/mL, respectively. sUA decreased and uUA excretion increased compared with baseline following verinurad + allopurinol (Study 1) or verinurad (Study 2). When accounting for dose, the steady-state pharmacokinetics of verinurad following multiple dosing were comparable between healthy Asian and Chinese participants and healthy non-Asian participants. Verinurad treatments were well tolerated, including at higher verinurad exposures than previously evaluated after repeated dosing.
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Affiliation(s)
- Susanne Johansson
- Clinical Pharmacology & Quantitative PharmacologyClinical Pharmacology & Safety SciencesAstraZeneca BioPharmaceuticals Research and Development GothenburgMölndalSweden
| | - David Han
- Parexel Early Phase Clinical Unit Los AngelesGlendaleCaliforniaUSA
| | | | - Karin Björck
- Biometrics CVRMAstraZeneca BioPharmaceuticals Research and DevelopmentGothenburgMölndalSweden
| | - Delia Florica
- Patient SafetyAstraZeneca BioPharmaceuticals Research and DevelopmentGothenburgSweden
| | - Michael Gillen
- Formerly of AstraZeneca BioPharmaceuticals Research and DevelopmentGaithersburgMarylandUSA
| | - Jesse Hall
- Formerly of Ardea Biosciences, IncSan DiegoCaliforniaUSA
| | - Fredrik Erlandsson
- CVRM Late ClinicalAstraZeneca BioPharmaceuticals Research and Development GothenburgMölndalSweden
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Choy SH, Nyanatay SA, Sothilingam S, Malek R, J. R. S, Toh CC, Sundram M, Md Yusoff NA, Nagappan P, Kamaruzaman S, Yeoh WS, Ong TA, Lim J. Cardiovascular risk factors, ethnicity and infection stone are independent factors associated with reduced renal function in renal stone formers. PLoS One 2022; 17:e0265510. [PMID: 35421118 PMCID: PMC9009641 DOI: 10.1371/journal.pone.0265510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 03/02/2022] [Indexed: 11/19/2022] Open
Abstract
Background Recent evidence suggested the link between nephrolithiasis and renal function impairment. We aimed to determine the renal function profile and potential factors associated with reduced renal function amongst renal stone formers in multi-ethnic Asians. Methods We conducted a cross-sectional study involving patients undergoing percutaneous nephrolithotomy between May 2015 and December 2019. Reduced renal function was defined as having estimated glomerular filtration rate < 60 ml/min per 1.73 m2. Renal stone samples were collected and quantified using infrared spectroscopy. Potential factors associated with reduced renal function including age, ethnicity, educational level, history of diabetes, hypertension, gout, hydronephrosis, serum uric acid level, and type of renal stone were evaluated using univariable and multivariable analyses. Results A total of 1162 patients from a multi-ethnic population (Malays 67%, Chinese 19%, Indians 13% and indigenous people 1%) with median age of 57 years (Interquartile range 48–64) were enrolled in the study. Almost a third of patients were found with reduced renal function. Multivariable analysis showed that the odds of having reduced renal function increased with age, ethnicity, lower educational level, history of diabetes, hypertension, gout, bilateral hydronephrosis, elevated serum uric acid level and infection stone. Conclusions Reduced renal function varies between ethnicities and all age groups of renal stone formers. In addition to age and ethnicity, cardiovascular risk factors including diabetes and hypertension may also need to be taken into account in managing stone patients with reduced renal function.
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Affiliation(s)
- Seow Huey Choy
- Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Selina Ann Nyanatay
- Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Rohan Malek
- Department of Urology, Hospital Selayang, Selangor, Malaysia
- * E-mail: (JL); (RM)
| | | | - Charng Chee Toh
- Department of Urology, Hospital Selayang, Selangor, Malaysia
| | - Murali Sundram
- Department of Urology, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | | | | | - Shakirin Kamaruzaman
- Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Wei Sien Yeoh
- Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Teng Aik Ong
- Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Jasmine Lim
- Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- * E-mail: (JL); (RM)
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Abstract
Gout is the most common inflammatory arthritis in the United States. Gouty arthritis is associated with significant morbidity and mortality and is the result of chronic hyperuricemia. Gout is effectively managed and potentially cured by decreasing the overall urate burden with serum urate-lowering therapy. When serum urate is maintained at less than 6.0 mg/dL, urate deposition is resolved, and gout can be cured. Unfortunately, because of less than optimal physician monitoring and dose escalation, many patients do not achieve these urate levels.
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Affiliation(s)
- Sarah F Keller
- Department of Rheumatic & Immunologic Diseases, The Cleveland Clinic, 9500 Euclid Avenue A50, Cleveland, OH 44915, USA.
| | - Brian F Mandell
- Department of Rheumatic & Immunologic Diseases, The Cleveland Clinic, 9500 Euclid Avenue A50, Cleveland, OH 44915, USA
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Wei J, Choi HK, Neogi T, Dalbeth N, Terkeltaub R, Stamp LK, Lyu H, McCormick N, Niu J, Zeng C, Lei G, Zhang Y. Allopurinol Initiation and All-Cause Mortality Among Patients With Gout and Concurrent Chronic Kidney Disease : A Population-Based Cohort Study. Ann Intern Med 2022; 175:461-470. [PMID: 35073156 PMCID: PMC10445508 DOI: 10.7326/m21-2347] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Two recent randomized clinical trials of escalating doses of allopurinol for the progression of chronic kidney disease (CKD) reported no benefits but potentially increased risk for death. Whether the risk could occur in patients with gout and concurrent CKD remains unknown. OBJECTIVE To examine the relation of allopurinol initiation, allopurinol dose escalation, and achieving target serum urate (SU) level after allopurinol initiation to all-cause mortality in patients with both gout and CKD. DESIGN Cohort study. SETTING The Health Improvement Network U.K. primary care database (2000 to 2019). PARTICIPANTS Patients aged 40 years or older who had gout and concurrent moderate-to-severe CKD. MEASUREMENTS The association between allopurinol initiation and all-cause mortality over 5-year follow-up in propensity score (PS)-matched cohorts was examined. Analysis of hypothetical trials were emulated: achieving target SU level (<0.36 mmol/L) versus not achieving target SU level and dose escalation versus no dose escalation for mortality over 5-year follow-up in allopurinol initiators. RESULTS Mortality was 4.9 and 5.8 per 100 person-years in 5277 allopurinol initiators and 5277 PS-matched noninitiators, respectively (hazard ratio [HR], 0.85 [95% CI, 0.77 to 0.93]). In the target trial emulation analysis, the HR of mortality for the achieving target SU level group compared with the not achieving target SU level group was 0.87 (CI, 0.75 to 1.01); the HR of mortality for allopurinol in the dose escalation group versus the no dose escalation group was 0.88 (CI, 0.73 to 1.07). LIMITATION Residual confounding cannot be ruled out. CONCLUSION In this population-based data, neither allopurinol initiation, nor achieving target SU level with allopurinol, nor allopurinol dose escalation was associated with increased mortality in patients with gout and concurrent CKD. PRIMARY FUNDING SOURCE Project Program of National Clinical Research Center for Geriatric Disorders.
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Affiliation(s)
- Jie Wei
- Health Management Center, Xiangya Hospital, Central South University, Changsha, China (J.W.)
| | - Hyon K Choi
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, and the Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (H.K.C., Y.Z.)
| | - Tuhina Neogi
- Section of Rheumatology, Boston University School of Medicine, Boston, Massachusetts (T.N.)
| | - Nicola Dalbeth
- Department of Medicine, University of Auckland, Auckland, New Zealand (N.D.)
| | - Robert Terkeltaub
- Rheumatology, Allergy-Immunology Section, San Diego VA Medical Center, San Diego, California (R.T.)
| | - Lisa K Stamp
- Department of Medicine, University of Otago, Christchurch, New Zealand (L.K.S.)
| | - Houchen Lyu
- Department of Orthopedics, General Hospital of Chinese PLA, Beijing, and Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China (H.L.)
| | - Natalie McCormick
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, and the Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, and Arthritis Research Canada, Richmond, British Columbia, Canada (N.M.)
| | - Jingbo Niu
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas (J.N.)
| | - Chao Zeng
- Department of Orthopaedics, Xiangya Hospital, Central South University, and Hunan Key Laboratory of Joint Degeneration and Injury, and National Clinical Research Center of Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China (C.Z.)
| | - Guanghua Lei
- Department of Orthopaedics, Xiangya Hospital, Central South University, and National Clinical Research Center of Geriatric Disorders, Xiangya Hospital, Central South University, and Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, China (G.L.)
| | - Yuqing Zhang
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, and the Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (H.K.C., Y.Z.)
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Serum Uric Acid Is a Weak Independent Predictor of Overall Survival in Older Adults. J Clin Med 2021; 10:jcm10194505. [PMID: 34640521 PMCID: PMC8509603 DOI: 10.3390/jcm10194505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 09/25/2021] [Accepted: 09/28/2021] [Indexed: 12/11/2022] Open
Abstract
Hyperuricemia accompanies many pathologies that contribute to overall death rate. The population-based multifaceted study of older adults in Poland made it possible to assess the effect of serum uric acid (SUA) on overall mortality. The PolSenior study performed between 2007–2011 included 3926 participants aged 65 years or above (mean age 79 ± 9 years) not treated with xanthin oxidase inhibitors (XOI) who were stratified by sex and SUA concentration into six subgroups increasing by 1 mg/dL. In 2019, survival data were retrieved from the population register. The crude risk of death was significantly higher in men and women with SUA ≥ 7 mg/dL. After adjustment to statistically significant factors, SUA remained a risk factor of death in men with SUA ≥ 8 mg/dL only, potentially due to the limited number of women with high SUA levels. Furthermore, age, heart failure, diabetes, and activities of daily living ≤ 4 pts were identified as factors increasing mortality risk regardless of sex. The risk of death increased also with smoking, past stroke, COPD/asthma, and hs-CRP > 3 mg/dL for men; and eGFR < 45 mL/min/1.73 m2, mini nutritional assessment ≤ 7 pts, and loop diuretics use for women. Mild hyperuricemia is a significant health status marker and an independent risk factor for overall mortality in older Caucasians not receiving XOI. Increased mortality is mostly limited to subjects with SUA levels ≥ 8 mg/dL.
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Isakov O, Patibandla BK, Shwartz D, Mor E, Christopher KB, Hod T. Can uric acid blood levels in renal transplant recipients predict allograft outcome? Ren Fail 2021; 43:1240-1249. [PMID: 34433378 PMCID: PMC8405090 DOI: 10.1080/0886022x.2021.1969246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Hyperuricemia is common after renal transplantation, especially in those receiving calcineurin inhibitors. Little, however, is known about the relationship between uric acid (UA) levels and allograft outcome. Methods We conducted a retrospective single-center analysis (N = 368) in order to assess UA blood levels post-transplant association with allograft outcome. For this study, a median serum UA level of all measured UA levels from 1 month to 1 year post renal transplantation was calculated. Results Patients were divided into 2 groups based on the median UA level measured between 1 and 12 months post-transplant. Those with median UA level ≥ 7 and ≥ 6 mg/dL (N = 164) versus median UA level < 7 and < 6 mg/dL for men and women respectively (N = 204) had lower GFR values at 1, 3 and 5 years posttransplant (mean GFR ± SD of 43.4 ± 20.6 and 58 ± 19.9 at 3 years post-transplant, p < 0.001). In multivariate models, UA levels were no longer significantly associated with renal allograft function. In a multivariate cox proportional hazard model, UA level was found to be independently associated with increased risk for death-censored graft loss (HR of 1.3, 95% CI 1.0–1.7, p < 0.05 for every increase of 1 mg/dL in UA level). Conclusion Hyperuricemia was found to be associated with increased death- censored graft loss but not with allograft function. Increased UA levels were not found to be an independent predictor of long-term allograft function despite the known association of hyperuricemia with the progression of cardiovascular and renal disease.
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Affiliation(s)
- Ofer Isakov
- Department of Internal Medicine "T", Tel Aviv Souraski Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Bhanu K Patibandla
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Doron Shwartz
- Department of Nephrology, Souraski Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Eytan Mor
- Renal Transplant Center, Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Kenneth B Christopher
- Renal Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Tammy Hod
- Renal Transplant Center, Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel.,Department of Nephrology, Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
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Abstract
Gout is the most common inflammatory arthritis in the United States. Gouty arthritis is associated with significant morbidity and mortality and is caused by hyperuricemia. Gout is effectively managed and potentially cured by decreasing the overall urate burden with serum urate-lowering therapy. When serum urate is maintained at less than 6.0 mg/dL urate deposition is resolved and gout can be cured. Unfortunately, owing to a lack of physician monitoring and dose escalation the majority of patients do not achieve these urate levels.
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Affiliation(s)
- Sarah F Keller
- Department of Rheumatic and Immunologic Diseases, The Cleveland Clinic, 9500 Euclid Avenue A50, Cleveland, OH 44915, USA.
| | - Brian F Mandell
- Department of Rheumatic and Immunologic Diseases, The Cleveland Clinic, 9500 Euclid Avenue A50, Cleveland, OH 44915, USA
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Weisman A, Tomlinson GA, Lipscombe LL, Garg AX, Perkins BA, Cherney DZI, Hawker GA. Allopurinol and Renal Outcomes in Adults With and Without Type 2 Diabetes: A Retrospective, Population-Based Cohort Study and Propensity Score Analysis. Can J Diabetes 2021; 45:641-649.e4. [PMID: 33714662 DOI: 10.1016/j.jcjd.2021.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/13/2020] [Accepted: 01/12/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Elevated uric acid (UA) is common in diabetes and is implicated in the pathogenesis of chronic kidney disease (CKD). Lowering UA with allopurinol may delay CKD progression. We assessed the association between allopurinol and renal outcomes in older adults both with and without diabetes, and whether this differed by diabetes status. METHODS We conducted a population-based, retrospective cohort study of older adults ≥66 years of age with a gout flare using administrative data from Ontario, Canada. The primary outcome was doubling of creatinine or kidney failure. Secondary outcomes were a composite of death or kidney failure, decline in estimated glomerular filtration rate by >30%, death and kidney failure. New allopurinol users were compared with nonusers using Cox proportional hazards models and inverse probability of treatment weighting (IPTW). An interaction between allopurinol use and presence or absence of diabetes was assessed. RESULTS Among 5,937 older adults with a gout flare (1,911 with diabetes), 1,304 (22%) were newly treated with allopurinol. Median follow-up time was 1.11 (interquartile range, 0.33 to 3.21) years for allopurinol users and 3.38 (interquartile range, 1.42 to 4.43) years for nonusers. There was no association between allopurinol use and the primary outcome (IPTW-adjusted hazard ratio, 0.97; 95% confidence interval, 0.72 to 1.31), and this did not differ by diabetes status. Allopurinol use was not associated with any of the secondary outcomes. CONCLUSIONS Allopurinol use was not associated with renal outcomes in older adults with or without diabetes. This supports the interpretation of UA as a biomarker of CKD risk rather than a modifiable target for prevention or treatment of CKD.
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Affiliation(s)
- Alanna Weisman
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.
| | - George A Tomlinson
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, University Health Network/Mt Sinai Hospital, Toronto, Ontario, Canada
| | - Lorraine L Lipscombe
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - Amit X Garg
- ICES, Toronto, Ontario, Canada; Department of Medicine, Epidemiology & Biostatistics, Western University Hospital Research Institute, Toronto, Ontario, Canada
| | - Bruce A Perkins
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - David Z I Cherney
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, Division of Nephrology, University Health Network, Toronto General, Toronto, Ontario, Canada
| | - Gillian A Hawker
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
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Borghi C, Agabiti-Rosei E, Johnson RJ, Kielstein JT, Lurbe E, Mancia G, Redon J, Stack AG, Tsioufis KP. Hyperuricaemia and gout in cardiovascular, metabolic and kidney disease. Eur J Intern Med 2020; 80:1-11. [PMID: 32739239 DOI: 10.1016/j.ejim.2020.07.006] [Citation(s) in RCA: 129] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/16/2020] [Accepted: 07/07/2020] [Indexed: 02/07/2023]
Abstract
During the last century, there has been an increasing prevalence of hyperuricaemia noted in many populations. While uric acid is usually discussed in the context of gout, hyperuricaemia is also associated with hypertension, chronic kidney disease, hypertriglyceridaemia, obesity, atherosclerotic heart disease, metabolic syndrome, and type 2 diabetes. Here we review the connection between hyperuricaemia and cardiovascular, kidney and metabolic diseases. Contrary to the popular view that uric acid is an inert metabolite of purine metabolism, recent studies suggest serum uric acid may have a variety of pro-inflammatory, pro-oxidative and vasoconstrictive actions that may contribute to cardiometabolic diseases. Hyperuricaemia is a predictive factor for the development of hypertension, metabolic syndrome, type 2 diabetes, coronary artery disease, left ventricular hypertrophy, atrial fibrillation, myocardial infarction, stroke, heart failure and chronic kidney disease. Treatment with uric acid-lowering therapies has also been found to improve outcomes in patients with hypertension and kidney disease, in some but not all studies. In conclusion, uric acid is emerging as a potentially treatable risk factor for cardiometabolic diseases, and more clinical trials investigating the potential benefit of lowering serum uric acid are recommended in individuals with hyperuricaemia with and without deposition and concomitant hypertension, metabolic syndrome or chronic kidney disease.
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Affiliation(s)
- Claudio Borghi
- Department of Medical and Surgical Sciences, Ospedale Malpighi, University of Bologna, Via Albertoni 15, 40138 Bologna, Italy.
| | - Enrico Agabiti-Rosei
- Department of Clinical and Experimental Sciences, University of Brescia Division of Medicine, Viale Europa, 11 - 25123 Brescia, Italy
| | - Richard J Johnson
- Department of Medicine, University of Colorado Anschutz Medical Campus, 12700 East 19th Ave Aurora, Colorado, United States
| | - Jan T Kielstein
- Medical Clinic V: Nephrology, Rheumatology and Blood Purification, Academic Teaching Hospital Braunschweig, Salzdahlumer Straße 90, 38126, Braunschweig, Germany
| | - Empar Lurbe
- Pediatric Department, General Hospital of Valencia and CIBERObn, Av. Menéndez Pelayo 4, 46010 Valencia, Spain
| | - Giuseppe Mancia
- University of Milano-Bicocca, Piazza dell'AteneoNuovo, 1, 20126 Milan and Policlinico di Monza, Monza, Italy
| | - Josep Redon
- Hospital Clinic of Valencia, INCLIVA University of Valencia and CIBERObn, Av. Menéndez Pelayo 4, 46010 Valencia, Spain
| | - Austin G Stack
- Department of Nephrology, University Hospital Limerick, Graduate Entry Medical School, University of Limerick, Castletroy, Co. Limerick, V94 T9PX, Ireland
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FitzGerald JD, Dalbeth N, Mikuls T, Brignardello-Petersen R, Guyatt G, Abeles AM, Gelber AC, Harrold LR, Khanna D, King C, Levy G, Libbey C, Mount D, Pillinger MH, Rosenthal A, Singh JA, Sims JE, Smith BJ, Wenger NS, Sharon Bae S, Danve A, Khanna PP, Kim SC, Lenert A, Poon S, Qasim A, Sehra ST, Sharma TSK, Toprover M, Turgunbaev M, Zeng L, Zhang MA, Turner AS, Neogi T. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis Care Res (Hoboken) 2020; 72:744-760. [PMID: 32391934 PMCID: PMC10563586 DOI: 10.1002/acr.24180] [Citation(s) in RCA: 336] [Impact Index Per Article: 84.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 02/28/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To provide guidance for the management of gout, including indications for and optimal use of urate-lowering therapy (ULT), treatment of gout flares, and lifestyle and other medication recommendations. METHODS Fifty-seven population, intervention, comparator, and outcomes questions were developed, followed by a systematic literature review, including network meta-analyses with ratings of the available evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and patient input. A group consensus process was used to compose the final recommendations and grade their strength as strong or conditional. RESULTS Forty-two recommendations (including 16 strong recommendations) were generated. Strong recommendations included initiation of ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares; allopurinol as the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage >3); using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (<40 mg/day); and a treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, with an SU target of <6 mg/dl. When initiating ULT, concomitant antiinflammatory prophylaxis therapy for a duration of at least 3-6 months was strongly recommended. For management of gout flares, colchicine, nonsteroidal antiinflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) were strongly recommended. CONCLUSION Using GRADE methodology and informed by a consensus process based on evidence from the current literature and patient preferences, this guideline provides direction for clinicians and patients making decisions on the management of gout.
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Affiliation(s)
- John D. FitzGerald
- University of California, Los Angeles and VA Greater Los Angeles Health Care System, Los Angeles, California
| | | | - Ted Mikuls
- University of Nebraska Medical Center and VA Nebraska–Western Iowa Health Care System, Omaha, Nebraska
| | | | | | | | | | - Leslie R. Harrold
- University of Massachusetts Medical School, Worcester Massachusetts, and Corrona, Waltham, Massachusetts
| | | | | | | | - Caryn Libbey
- Boston University School of Medicine, Boston, Massachusetts
| | - David Mount
- VA Boston Healthcare System, Boston, Massachusetts
| | | | | | - Jasvinder A. Singh
- University of Alabama at Birmingham and Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
| | | | - Benjamin J. Smith
- Florida State University College of Medicine School of Physician Assistant Practice, Tallahassee
| | | | | | | | - Puja P. Khanna
- University of Michigan, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Seoyoung C. Kim
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Samuel Poon
- US Department of Veterans Affairs, Manchester, New Hampshire
| | - Anila Qasim
- McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | - Linan Zeng
- McMaster University, Hamilton, Ontario, Canada
| | - Mary Ann Zhang
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Tuhina Neogi
- Boston University School of Medicine, Boston, Massachusetts
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12
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Cheng ZY, Feng YZ, Liu XL, Ye YJ, Hu JJ, Cai XR. Diffusional kurtosis imaging of kidneys in patients with hyperuricemia: initial study. Acta Radiol 2020; 61:839-847. [PMID: 31610679 DOI: 10.1177/0284185119878362] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND At present, there remains a lack of a reliable indicator for monitoring renal function in patients with hyperuricemia. PURPOSE This study aimed to evaluate the feasibility of diffusion kurtosis imaging in the assessment of renal function in patients with hyperuricemia. MATERIAL AND METHODS A total of 75 male participants, including 25 with asymptomatic hyperuricemia, 25 with gouty arthritis, and 25 age-matched male healthy controls, were enrolled in this study. Diffusion kurtosis imaging data were acquired to derive axial (Ka), radial (Kr), and mean kurtosis (MK), fractional anisotropy, axial (Da), radial (Dr), and mean diffusivity (MD) for comparisons among the three groups. They were also correlated with estimated glomerular filtration rate (eGFR). RESULTS The MK values of the renal cortex and medulla and Kr value of the renal medulla in patients with asymptomatic hyperuricemia and gouty arthritis significantly increased compared with those in the controls (P < 0.05). Patients with gouty arthritis showed significant higher cortical and medullary Ka values compared with the other two groups (P < 0.05). The cortical Kr values of the asymptomatic hyperuricemia and gouty arthritis patients were significantly higher than that of the controls (P < 0.05). The medullary fractional anisotropy value showed a significant difference between the control and gouty arthritis groups (P < 0.05). No correlation was found between any diffusion kurtosis imaging parameters and eGFR value. CONCLUSION Diffusion kurtosis imaging is feasible in the assessment of the early changes of renal cortex and medulla in patients with hyperuricemia.
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Affiliation(s)
- Zhong-Yuan Cheng
- Medical Imaging Center, the First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, PR China
- *Equal contributors
| | - You-Zhen Feng
- Medical Imaging Center, the First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, PR China
- *Equal contributors
| | - Xiao-Ling Liu
- Medical Imaging Center, Guangdong Provincial Hospital of Traditional Chinese Medicine Zhuhai Branch, Guangdong, PR China
| | - Yao-Jiang Ye
- Medical Imaging Center, the First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, PR China
| | - Jun-Jiao Hu
- Medical Imaging Center, the First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, PR China
| | - Xiang-Ran Cai
- Medical Imaging Center, the First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, PR China
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13
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FitzGerald JD, Dalbeth N, Mikuls T, Brignardello-Petersen R, Guyatt G, Abeles AM, Gelber AC, Harrold LR, Khanna D, King C, Levy G, Libbey C, Mount D, Pillinger MH, Rosenthal A, Singh JA, Sims JE, Smith BJ, Wenger NS, Bae SS, Danve A, Khanna PP, Kim SC, Lenert A, Poon S, Qasim A, Sehra ST, Sharma TSK, Toprover M, Turgunbaev M, Zeng L, Zhang MA, Turner AS, Neogi T. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis Rheumatol 2020; 72:879-895. [PMID: 32390306 DOI: 10.1002/art.41247] [Citation(s) in RCA: 177] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 02/28/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To provide guidance for the management of gout, including indications for and optimal use of urate-lowering therapy (ULT), treatment of gout flares, and lifestyle and other medication recommendations. METHODS Fifty-seven population, intervention, comparator, and outcomes questions were developed, followed by a systematic literature review, including network meta-analyses with ratings of the available evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and patient input. A group consensus process was used to compose the final recommendations and grade their strength as strong or conditional. RESULTS Forty-two recommendations (including 16 strong recommendations) were generated. Strong recommendations included initiation of ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares; allopurinol as the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage >3); using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (<40 mg/day); and a treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, with an SU target of <6 mg/dl. When initiating ULT, concomitant antiinflammatory prophylaxis therapy for a duration of at least 3-6 months was strongly recommended. For management of gout flares, colchicine, nonsteroidal antiinflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) were strongly recommended. CONCLUSION Using GRADE methodology and informed by a consensus process based on evidence from the current literature and patient preferences, this guideline provides direction for clinicians and patients making decisions on the management of gout.
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Affiliation(s)
- John D FitzGerald
- University of California, Los Angeles and VA Greater Los Angeles Health Care System, Los Angeles, California
| | | | - Ted Mikuls
- University of Nebraska Medical Center and VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska
| | | | | | - Aryeh M Abeles
- New York University School of Medicine, New York City, New York
| | | | - Leslie R Harrold
- University of Massachusetts Medical School, Worcester Massachusetts, and Corrona, Waltham, Massachusetts
| | | | | | | | - Caryn Libbey
- Boston University School of Medicine, Boston, Massachusetts
| | - David Mount
- VA Boston Healthcare System, Boston, Massachusetts
| | | | | | - Jasvinder A Singh
- University of Alabama at Birmingham and Birmingham Veterans Affairs Medical Center, Birmingham
| | | | - Benjamin J Smith
- Florida State University College of Medicine School of Physician Assistant Practice, Tallahassee
| | | | | | | | - Puja P Khanna
- University of Michigan, VA Ann Arbor Healthcare System, Ann Arbor
| | - Seoyoung C Kim
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Samuel Poon
- US Department of Veterans Affairs, Manchester, New Hampshire
| | - Anila Qasim
- McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | - Linan Zeng
- McMaster University, Hamilton, Ontario, Canada
| | - Mary Ann Zhang
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Tuhina Neogi
- Boston University School of Medicine, Boston, Massachusetts
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14
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Brucato A, Cianci F, Carnovale C. Management of hyperuricemia in asymptomatic patients: A critical appraisal. Eur J Intern Med 2020; 74:8-17. [PMID: 31952982 DOI: 10.1016/j.ejim.2020.01.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/02/2020] [Accepted: 01/04/2020] [Indexed: 02/07/2023]
Abstract
While there is consensus on starting urate-lowering therapy (ULT) in cases of symptomatic hyperuricemia, the frequent condition of asymptomatic hyperuricemia (AH) remains a challenge due to differences in the findings of studies that have addressed the issue. Uric acid has anti-oxidant properties, but high levels predispose to gout and may play a role in metabolic syndrome. We systematically evaluated randomized controlled trials (RCTs) addressing ULT in patients with AH, to assess the current evidence. We found broad heterogeneity among the studies (13 RCTs), in terms of study design and population, making findings challenging to interpret and generalize; hard end-points were not assessed. Allopurinol is often prescribed for AH despite the fact that its use is not backed by conclusive evidence from prospective RCTs, nor is it recommended by the guidelines. Its potential benefits, in terms of absolute risk reduction, must be weighed against its potential for harm since it can trigger severe adverse hypersensitivity reactions, sometimes even fatal. RCTs with hard end-points are needed to assess the risk/benefit of lowering uric acid in subjects with AH, particularly as secondary prevention for cardiovascular risk and in patients with different degrees of renal disease. To date, particularly after the result from the CARES trial, preventive treatment of asymptomatic and non-severe hyperuricemia is not recommended.
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Affiliation(s)
- Antonio Brucato
- Department of biomedical and clinical sciences, Università di Milano, Fatebenefratelli Hospital, Milan, Italy
| | | | - Carla Carnovale
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano, Via GB Grassi 74, Milan, 20157, Italy.
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15
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Hsu YSO, Wu IW, Chang SH, Lee CC, Tsai CY, Lin CY, Lin WT, Huang YT, Wu CY, Kuo G, Hsiao CY, Lin HL, Yang CC, Yen TH, Chen YC, Hung CC, Tian YC, Kuo CF, Yang CW, Anderson GF, Yang HY. Comparative Renoprotective Effect of Febuxostat and Allopurinol in Predialysis Stage 5 Chronic Kidney Disease Patients: A Nationwide Database Analysis. Clin Pharmacol Ther 2019; 107:1159-1169. [PMID: 31628864 PMCID: PMC7232862 DOI: 10.1002/cpt.1697] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 09/19/2019] [Indexed: 12/11/2022]
Abstract
Hyperuricemia has been associated with chronic kidney disease (CKD) progression. The antihyperuricemic febuxostat's potential renoprotective effect has been demonstrated in stage 1–3 CKD. Large‐scale studies comparing the renoprotective potential of febuxostat and allopurinol in advanced CKD are lacking. We exclusively selected 6,057 eligible patients with predialysis stage 5 CKD prescribed either febuxostat or allopurinol using the National Health Insurance Research Database in Taiwan during 2012–2015. There were 69.57% of allopurinol users and 42.01% febuxostat users who required long‐term dialysis (P < 0.0001). The adjusted hazard ratio (HR) of 0.65 (95% confidence interval (CI) 0.60–0.70) indicated near 35% lower hazards of long‐term dialysis with febuxostat use. The renal benefit of febuxostat was consistent across most patient subgroups and/or using the propensity score‐matched cohort. The adjusted HR was 0.66 (95% CI, 0.61–0.70) for long‐term dialysis or death. In conclusion, lower risk of progression to dialysis was observed in predialysis stage 5 CKD febuxostat users without compromising survival.
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Affiliation(s)
- Yun-Shiuan O Hsu
- Kidney Research Institute, Nephrology Department, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - I-Wen Wu
- Nephrology Department, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Shang-Hung Chang
- Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Cheng-Chia Lee
- Kidney Research Institute, Nephrology Department, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chung-Ying Tsai
- Kidney Research Institute, Nephrology Department, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chan-Yu Lin
- Kidney Research Institute, Nephrology Department, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wan-Ting Lin
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yu-Tung Huang
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chao-Yi Wu
- Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - George Kuo
- Kidney Research Institute, Nephrology Department, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Yen Hsiao
- Division of Nephrology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi County, Taiwan
| | - Hsing-Lin Lin
- Division of Critical Care Surgery, Department of Critical Care Medicine, Veterans General Hospital, Kaohsiung, Taiwan
| | - Chih-Chao Yang
- Nephrology Department, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Tzung-Hai Yen
- Kidney Research Institute, Nephrology Department, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yung-Chang Chen
- Kidney Research Institute, Nephrology Department, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Chieh Hung
- Kidney Research Institute, Nephrology Department, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ya-Chong Tian
- Kidney Research Institute, Nephrology Department, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chang-Fu Kuo
- Division of Rheumatology, Allergy, and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chih-Wei Yang
- Kidney Research Institute, Nephrology Department, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Gerard F Anderson
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Huang-Yu Yang
- Kidney Research Institute, Nephrology Department, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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16
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Stack AG, Johnson ME, Blak B, Klein A, Carpenter L, Morlock R, Maguire AR, Parsons VL. Gout and the risk of advanced chronic kidney disease in the UK health system: a national cohort study. BMJ Open 2019; 9:e031550. [PMID: 31462487 PMCID: PMC6720233 DOI: 10.1136/bmjopen-2019-031550] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE Evaluate the association between gout and risk of advanced chronic kidney disease (CKD). DESIGN Retrospective matched cohort study. SETTING UK Clinical Practice Research Datalink. PARTICIPANTS The analysis included data for 68 897 patients with gout and 554 964 matched patients without gout. Patients were aged ≥18 years, registered at UK practices, had ≥12 months of clinical data and had data linked with Hospital Episode Statistics. Patients were excluded for history of advanced CKD, juvenile gout, cancer, HIV, tumour lysis syndrome, Lesch-Nyhan syndrome or familial Mediterranean fever. PRIMARY AND SECONDARY OUTCOME MEASURES Advanced CKD was defined as first occurrence of: (1) dialysis, kidney transplant, diagnosis of end-stage kidney disease (ESKD) or stage 5 CKD (diagnostic codes in Read system or International Classification of Diseases, Tenth Revision); (2) estimated glomerular filtration rate (eGFR) <10 mL/min/1.73 m²; (3) doubling of serum creatinine from baseline and (4) death associated with CKD. RESULTS Advanced CKD incidence was higher for patients with gout (8.54 per 1000 patient-years; 95% CI 8.26 to 8.83) versus without gout (4.08; 95% CI 4.00 to 4.16). Gout was associated with higher advanced CKD risk in both unadjusted analysis (HR, 2.00; 95% CI 1.92 to 2.07) and after adjustment (HR, 1.29; 95% CI 1.23 to 1.35). Association was strongest for ESKD (HR, 2.13; 95% CI 1.73 to 2.61) and was present for eGFR <10 mL/min/1.73 m² (HR, 1.45; 95% CI 1.30 to 1.61) and serum creatinine doubling (HR, 1.13; 95% CI 1.08 to 1.19) but not CKD-associated death (HR, 1.14; 95% CI 0.99 to 1.31). Association of gout with advanced CKD was replicated in propensity-score matched analysis (HR, 1.23; 95% CI 1.17 to 1.29) and analysis limited to patients with incident gout (HR, 1.28; 95% CI 1.22 to 1.35). CONCLUSIONS Gout is associated with elevated risk of CKD progression. Future studies should investigate whether controlling gout is protective and reduces CKD risk.
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Affiliation(s)
- Austin G Stack
- Graduate Entry Medical School & Health Research Institute, University of Limerick, Limerick, Ireland
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17
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Jonsson H, Aspelund T, Eiriksdottir G, Harris TB, Launer LJ, Gudnason V. Hyperuricemia is associated with intermittent hand joint pain in a cross sectional study of elderly females: The AGES-Reykjavik Study. PLoS One 2019; 14:e0221474. [PMID: 31442261 PMCID: PMC6707588 DOI: 10.1371/journal.pone.0221474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 08/07/2019] [Indexed: 11/18/2022] Open
Abstract
Background The debate whether "asymptomatic hyperuricemia" should be treated is still ongoing. The objective of this cross-sectional study was to analyze whether hyperuricema in the elderly is associated with joint pain. Methods and findings Participants in the population-based AGES-Reykjavik Study (males 2195, females 2975, mean age 76(6)) answered standardized questions about joint pain. In addition they recorded intermittent hand joint pain by marking a diagram of the hand. In males, no association was found between hyperuricemia and pain. Females however, showed a positive association between hyperuricemia and joint pain at many sites. After adjustment for age, BMI and hand osteoarthritis however, only intermittent hand joint pain (OR 1.30(1.07–1.58), p = 0.008) and intermittent pain in ≥10 hand joints (OR 1.75(1.32–2.31), p<0.001) remained significant. The best model for describing the relationship between serum uric acid levels (SUA) and intermittent hand joint pain in ≥10 joints was non-linear with a cut-off at 372 μmol/L. The attributable surplus number of symptomatic females with SUA ≥372 μmol/L was approximately 2.0% of the study population for those reporting pain in ≥10 hand joints. Next after having severe hand osteoarthritis, SUA ≥372 was an independent predictive factor of intermittent pain in ≥10 hand joints. Intermittent hand joint pain was also an independent risk factor for worse general health description. Conclusion Results from this population based study indicate that hyperuricemia in elderly females may be a rather frequent cause of intermittent hand joint pain, often in many joints. The most likely explanation relates to low-grade urate crystal induced inflammation. Our data do not allow for assessment of the severity of symptoms or whether they merit specific treatment, but intermittent hand joint pain was an independent predictor of worse general health. These findings may be an important contribution to the debate on whether hyperuricemia should be treated.
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Affiliation(s)
- Helgi Jonsson
- Landspitalinn University Hospital, Reykjavík, Iceland
- University of Iceland, Reykjavik, Iceland
- * E-mail:
| | - Thor Aspelund
- University of Iceland, Reykjavik, Iceland
- Icelandic Heart Association, Kopavogur, Iceland
| | | | - Tamara B. Harris
- National Institute on Aging, Bethesda, MD, United States of America
| | - Lenore J. Launer
- National Institute on Aging, Bethesda, MD, United States of America
| | - Vilmundur Gudnason
- University of Iceland, Reykjavik, Iceland
- Icelandic Heart Association, Kopavogur, Iceland
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18
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Roumeliotis S, Roumeliotis A, Dounousi E, Eleftheriadis T, Liakopoulos V. Dietary Antioxidant Supplements and Uric Acid in Chronic Kidney Disease: A Review. Nutrients 2019; 11:nu11081911. [PMID: 31443225 PMCID: PMC6723425 DOI: 10.3390/nu11081911] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 08/10/2019] [Accepted: 08/12/2019] [Indexed: 02/07/2023] Open
Abstract
Increased serum levels of uric acid have been associated with the onset and development of chronic kidney disease (CKD), cardiovascular disease, and mortality, through several molecular pathogenetic mechanisms, such as inflammation and oxidative stress. Oxidative stress is present even in the early stages of CKD, progresses parallelly with the deterioration of kidney function, and is even more exacerbated in end-stage renal disease patients undergoing maintenance hemodialysis. Although acting in the plasma as an antioxidant, once uric acid enters the intracellular environment; it behaves as a powerful pro-oxidant. Exogenous intake of antioxidants has been repeatedly shown to prevent inflammation, atherosclerosis and oxidative stress in CKD patients. Moreover, certain antioxidants have been proposed to exert uric acid-lowering properties. This review aims to present the available data regarding the effects of antioxidant supplements on both oxidative stress and uric acid serum levels, in a population particularly susceptible to oxidative damage such as CKD patients.
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Affiliation(s)
- Stefanos Roumeliotis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54636, Greece
| | - Athanasios Roumeliotis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54636, Greece
| | - Evangelia Dounousi
- Department of Nephrology, School of Medicine, University of Ioannina, Ioannina 45110, Greece
| | | | - Vassilios Liakopoulos
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54636, Greece.
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19
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The Role of a “Treat-to-Target” Approach in the Long-Term Renal Outcomes of Patients with Gout. J Clin Med 2019; 8:jcm8071067. [PMID: 31330801 PMCID: PMC6678146 DOI: 10.3390/jcm8071067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 07/10/2019] [Accepted: 07/17/2019] [Indexed: 11/17/2022] Open
Abstract
Background: Although gout is accompanied by the substantial burden of kidney disease, there are limited data to assess renal function as a therapeutic target. This study evaluated the importance of implementing a “treat-to-target” approach in relation to renal outcomes. Methods: Patients with gout who underwent continuous urate-lowering therapy (ULT) for at least 12 months were included. The effect of ULT on renal function was investigated by means of a sequential comparison of the estimated glomerular filtration rate (eGFR). Results: Improvement in renal function was only demonstrated in subjects in whom the serum urate target of <6 mg/dL was achieved (76.40 ± 18.81 mL/min/1.73 m2 vs. 80.30 ± 20.41 mL/min/1.73 m2, p < 0.001). A significant difference in the mean change in eGFR with respect to serum urate target achievement was shown in individuals with chronic kidney disease stage 3 (−0.35 ± 3.87 mL/min/1.73 m2 vs. 5.33 ± 11.64 mL/min/1.73 m2, p = 0.019). Multivariable analysis predicted that patients ≥65 years old had a decreased likelihood of improvement (OR 0.31, 95% CI 0.13–0.75, p = 0.009). Conclusions: The “treat-to-target” approach in the long-term management of gout is associated with better renal outcomes, with a greater impact on those with impaired renal function.
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20
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Sato Y, Feig DI, Stack AG, Kang DH, Lanaspa MA, Ejaz AA, Sánchez-Lozada LG, Kuwabara M, Borghi C, Johnson RJ. The case for uric acid-lowering treatment in patients with hyperuricaemia and CKD. Nat Rev Nephrol 2019; 15:767-775. [PMID: 31296965 DOI: 10.1038/s41581-019-0174-z] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2019] [Indexed: 02/07/2023]
Abstract
Hyperuricaemia is common among patients with chronic kidney disease (CKD), and increases in severity with the deterioration of kidney function. Although existing guidelines for CKD management do not recommend testing for or treatment of hyperuricaemia in the absence of a diagnosis of gout or urate nephrolithiasis, an emerging body of evidence supports a direct causal relationship between serum urate levels and the development of CKD. Here, we review randomized clinical trials that have evaluated the effect of urate-lowering therapy (ULT) on the rate of CKD progression. Among trials in which individuals in the control arm experienced progressive deterioration of kidney function (which we define as ≥4 ml/min/1.73 m² over the course of the study - typically 6 months to 2 years), treatment with ULT conferred consistent clinical benefits. In contrast, among trials where clinical progression was not observed in the control arm, treatment with ULT was ineffective, but this finding should not be used as an argument against the use of uric acid-lowering therapy. Although additional studies are needed to identify threshold values of serum urate for treatment initiation and to confirm optimal target levels, we believe that sufficient evidence exists to recommend routine measurement of serum urate levels in patients with CKD and consider initiation of ULT among those who are hyperuricaemic with evidence of deteriorating renal function, unless specific contraindications exist.
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Affiliation(s)
- Yuka Sato
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Daniel I Feig
- Division of Pediatric Nephrology, University of Alabama, Birmingham, AL, USA
| | - Austin G Stack
- Division of Nephrology, Department of Medicine, University Hospital Limerick, Limerick, Ireland.,Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Duk-Hee Kang
- Division of Nephrology, Department of Internal Medicine, Ewha Womans University College of Medicine Ewha Medical Research Center, Seoul, South Korea
| | - Miguel A Lanaspa
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - A Ahsan Ejaz
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, FL, USA
| | - L Gabriela Sánchez-Lozada
- Laboratory of Renal Physiopathology, Department of Nephrology, INC Ignacio Chavez, Mexico City, Mexico
| | - Masanari Kuwabara
- Department of Cardiology and Intensive Care Unit, Toranomon Hospital, Tokyo, Japan
| | - Claudio Borghi
- Department of Medicine, University of Bologna, Bologna, Italy
| | - Richard J Johnson
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO, USA. .,Rocky Mountain Regional VA Medical Center, Aurora, CO, USA.
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21
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Singh JA, Cleveland JD. Gout is associated with a higher risk of chronic renal disease in older adults: a retrospective cohort study of U.S. Medicare population. BMC Nephrol 2019; 20:93. [PMID: 30876398 PMCID: PMC6420755 DOI: 10.1186/s12882-019-1274-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 03/03/2019] [Indexed: 12/16/2022] Open
Abstract
Background Hyperuricemia and gout have been linked to chronic kidney disease (CKD). Whether the increased risk of CKD in gout is due to shared risk factors such as hypertension, diabetes or heart disease, or due to gout itself is not known. Studies in older adults, who tend to have a high incidence of CKD, are limited. Our objective was to assess whether gout was associated with incident CKD in older adults. Methods Using the 5% random sample of Medicare claims, we assessed whether gout is associated with higher risk of incident (new) CKD in adults 65 years or older, using multivariable-adjusted Cox regression analyses, adjusting for demographics (age, gender, race), medical comorbidity and common medications. We calculated hazard ratios (HR) and 95% confidence interval (CI). Sensitivity analyses varied comorbidity variable (models 2, 3), or limited CKD to the most specific codes. Results Of the 1,699,613 eligible people, 168,065 developed incident CKD; 150,162 people without gout and 17,903 people with gout. Respective crude incidence rates were 15.6 vs. 78.1 per 1000 person-years. We found that gout was associated with a higher risk of incident CKD in multivariable-adjusted analyses, HR was 3.05 (95% CI, 2.99, 3.10), with minimal attenuation in sensitivity analyses, with HR 2.96 (95% CI, 2.91, 3.01) (model 2, categorical Charlson-Romano) and 2.59 (95% CI, 2.54, 2.63) (model 3, individual Charlson-Romano comorbidities plus hypertension, heart disease, obesity, coronary artery disease). Sensitivity analyses that limited the CKD diagnostic codes to more specific codes, confirmed findings from the main models with respective HRs of 3.10 (95% CI, 3.05, 3.15; Model 1), 3.03 (95% CI, 2.97, 3.08; Model 2) and 2.60 (95% CI, 2.56, 2.65; Model 3). Conclusion Gout was associated with a 3-fold higher risk of CKD, confirmed in multiple sensitivity analyses. Future studies should provide insights into underlying mechanisms that are responsible for an increased CKD risk in gout.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service, VA Medical Center, 510, 20th street South, FOT 805B, Birmingham, AL, 35233, USA. .,Department of Medicine at School of Medicine, University of Alabama at Birmingham, 1720 Second Ave. South, Birmingham, AL, 35294-0022, USA. .,Division of Epidemiology at School of Public Health, University of Alabama at Birmingham, 1720 Second Ave. South, Birmingham, AL, 35294-0022, USA. .,University of Alabama at Birmingham, Faculty Office Tower 805B, 510 20th Street S, Birmingham, AL, 35294-0022, USA.
| | - John D Cleveland
- Department of Medicine at School of Medicine, University of Alabama at Birmingham, 1720 Second Ave. South, Birmingham, AL, 35294-0022, USA
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Levy G, Shi JM, Cheetham TC, Rashid N. Urate-Lowering Therapy in Moderate to Severe Chronic Kidney Disease. Perm J 2019; 22:17-142. [PMID: 30201087 DOI: 10.7812/tpp/17-142] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
CONTEXT Hyperuricemia is an independent risk factor for progression of kidney disease. OBJECTIVE To determine whether lowering serum uric acid level (sUA) to below 6 mg/dL (target) improves mild to moderate chronic kidney disease (CKD) and whether CKD stage influences the benefit of lowering sUA to target. DESIGN Retrospective epidemiologic cohort study conducted over 8 years. Estimated glomerular filtration rate (eGFR) was required in the 6 months preceding the index date (defined as first occurrence of sUA < 7 mg/dL), and at least 1 sUA and eGFR were required during follow-up. Patients were urate-lowering therapy (ULT) naïve, aged 18 years or older, and had CKD Stages 2 to 4 at baseline. Health Plan enrollment with drug benefit was required. Exclusions included active cancer, dialysis, or other kidney disease. MAIN OUTCOME MEASURES A 30% decrease or 30% improvement in eGFR from baseline. RESULTS A total of 12,751 patients met inclusion criteria; 2690 patients received ULT during follow-up and 10,061 did not. Target sUA was achieved in 1118 patients (42%) receiving ULT. A 30% improvement in eGFR was likelier in patients who achieved the target (odds ratio [OR] = 1.78, p < 0.001). Pairwise comparison of CKD stages showed a 30% improvement in eGFR in CKD Stage 2 (OR = 2.26, p = 0.017) and Stage 3 (OR = 2.23, p < 0.001) but not Stage 4 (OR = 1.50, p = 0.081). CONCLUSION Patients who achieve an American College of Rheumatology target sUA below 6 mg/dL during ULT have higher rates of eGFR improvement, especially in CKD Stages 2 and 3.
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Affiliation(s)
- Gerald Levy
- Rheumatologist at the Downey Medical Center in CA
| | - Jiaxiao M Shi
- Researcher in Research and Evaluation for the Southern California Permanente Medical Group in Pasadena
| | - T Craig Cheetham
- Research Scientist in the College of Pharmacy at Western University of Health Sciences in Pomona, CA
| | - Nazia Rashid
- Researcher in Research and Evaluation in Drug Information Services for the Southern California Permanente Medical Group in Pasadena
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Vargas-Santos AB, Peloquin CE, Zhang Y, Neogi T. Association of Chronic Kidney Disease With Allopurinol Use in Gout Treatment. JAMA Intern Med 2018; 178:1526-1533. [PMID: 30304329 PMCID: PMC6248199 DOI: 10.1001/jamainternmed.2018.4463] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Clinicians are often cautious about use of allopurinol in patients with gout when renal function declines. OBJECTIVE To assess the association of allopurinol use in gout with the risk of developing chronic kidney disease stage 3 or higher. DESIGN, SETTING, AND PARTICIPANTS A time-stratified propensity score-matched, population-based, prospective cohort study of individuals with newly diagnosed gout who initiated allopurinol (≥300 mg/d) compared with those who did not initiate allopurinol, using the Health Improvement Network (THIN), a United Kingdom general practitioner electronic health records database, was carried out. The data were analyzed using Cox proportional hazards regression. Among adults aged 18 to 89 years with newly diagnosed gout, we propensity score matched 4760 initiators of allopurinol (≥300 mg/d) to the same number of noninitiators of allopurinol, excluding those with chronic kidney disease stage 3 or higher or urate-lowering therapy use before their gout diagnosis. EXPOSURES Allopurinol initiation at a dose of 300 mg or more per day. MAIN OUTCOMES AND MEASURES Development of chronic kidney disease stage 3 or higher. RESULTS Of the 4760 allopurinol initiators (3975 men, 785 women) and same number of noninitiators (3971 men, 789 women), 579 and 623, respectively, developed chronic kidney disease stage 3 or higher, with a mean follow-up time of 5 and 4 years, mean age of 57 years, and mean body mass index (calculated as weight in kilograms divided by height in meters squared) of 30 for both groups. Use of allopurinol of at least 300 mg/d was associated with lower risk of developing chronic kidney disease stage 3 or higher compared with nonusers, with a hazard ratio (HR) of 0.87 (95% CI, 0.77-0.97). Allopurinol initiation at less than 300 mg/d was not associated with renal function decline (HR, 1.00; 95% CI, 0.91-1.09). CONCLUSIONS AND RELEVANCE In this large cohort, allopurinol initiation of at least 300 mg/d was associated with a lower risk of renal function deterioration. Because allopurinol does not appear to be associated with renal function decline, clinicians should consider evaluating other potential causes when patients with gout experience renal function decline.
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Affiliation(s)
- Ana Beatriz Vargas-Santos
- Internal Medicine Department, Rheumatology Unit, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Christine E Peloquin
- Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, Massachusetts
| | - Yuqing Zhang
- Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, Massachusetts
| | - Tuhina Neogi
- Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, Massachusetts
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24
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Roughley M, Sultan AA, Clarson L, Muller S, Whittle R, Belcher J, Mallen CD, Roddy E. Risk of chronic kidney disease in patients with gout and the impact of urate lowering therapy: a population-based cohort study. Arthritis Res Ther 2018; 20:243. [PMID: 30376864 PMCID: PMC6235219 DOI: 10.1186/s13075-018-1746-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 10/15/2018] [Indexed: 01/10/2023] Open
Abstract
Background An association between gout and renal disease is well-recognised but few studies have examined whether gout is a risk factor for subsequent chronic kidney disease (CKD). Additionally, the impact of urate-lowering therapy (ULT) on development of CKD in gout is unclear. The objective of this study was to quantify the risk of CKD stage ≥ 3 in people with gout and the impact of ULT. Methods This was a retrospective cohort study using data from the Clinical Practice Research Datalink (CPRD). Patients with incident gout were identified from general practice medical records between 1998 and 2016 and randomly matched 1:1 to patients without a diagnosis of gout based on age, gender, available follow-up time and practice. Primary outcome was development of CKD stage ≥ 3 based on estimated glomerular filtration rate (eGFR) or recorded diagnosis. Absolute rates (ARs) and adjusted hazard ratios (HRs) were calculated using Cox regression models. Risk of developing CKD was assessed among those prescribed ULT within 1 and 3 years of gout diagnosis. Results Patients with incident gout (n = 41,446) were matched to patients without gout. Development of CKD stage ≥ 3 was greater in the exposed group than in the unexposed group (AR 28.6 versus 15.8 per 10,000 person-years). Gout was associated with an increased risk of incident CKD (adjusted HR 1.78 95% CI 1.70 to 1.85). Those exposed to ULT had a greater risk of incident CKD, but following adjustment this was attenuated to non-significance in all analyses (except on 3-year analysis of women (adjusted HR 1.31 95% CI 1.09 to 1.59)). Conclusions This study has demonstrated gout to be a risk factor for incident CKD stage ≥ 3. Further research examining the mechanisms by which gout may increase risk of CKD and whether optimal use of ULT can reduce the risk or progression of CKD in gout is suggested. Electronic supplementary material The online version of this article (10.1186/s13075-018-1746-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthew Roughley
- East London NHS Foundation Trust, Trust Headquarters, 9 Alie Street, London, E1 8DE, UK.
| | - Alyshah Abdul Sultan
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Lorna Clarson
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Sara Muller
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Rebecca Whittle
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - John Belcher
- School of Computing and Mathematics, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Christian D Mallen
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Edward Roddy
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK.,Haywood Academic Rheumatology Centre, Midland Partnership NHS Foundation Trust, Haywood Hospital, Burslem, Staffordshire, ST6 7AG, UK
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25
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Lopez-Pineda A, Cordero A, Carratala-Munuera C, Orozco-Beltran D, Quesada JA, Bertomeu-Gonzalez V, Gil-Guillen VF, Bertomeu-Martinez V. Association analysis between hyperuricemia and long term mortality after acute coronary syndrome in three subgroups of patients. Data Brief 2018. [PMID: 29516035 PMCID: PMC5834648 DOI: 10.1016/j.dib.2018.01.101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
These data are linked to the research article, entitled Hyperuricemia as a prognostic factor after acute coronary syndrome published in Atherosclerosis. Data from patients admitted for acute coronary syndrome between 2008 and 2013 were collected during the hospitalization, and a follow-up until endpoint or end of study was carried out. Multivariate analysis of variables associated with long term mortality after acute coronary syndrome in patients stratified by the presence of diabetes, hypertension or kidney failure is provided in this article.
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Affiliation(s)
- Adriana Lopez-Pineda
- Cardiology Department, Hospital of San Juan de Alicante, San Juan De Alicante, Spain.,Catedra de Medicina de Familia, Clinical Medicine Department, Miguel Hernandez University, San Juan de Alicante, Spain
| | - Alberto Cordero
- Cardiology Department, Hospital of San Juan de Alicante, San Juan De Alicante, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Hospital Clínico Universitario de Santiago de Compostela-SERGAS. Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Concepción Carratala-Munuera
- Catedra de Medicina de Familia, Clinical Medicine Department, Miguel Hernandez University, San Juan de Alicante, Spain
| | - Domingo Orozco-Beltran
- Catedra de Medicina de Familia, Clinical Medicine Department, Miguel Hernandez University, San Juan de Alicante, Spain
| | - Jose A Quesada
- Catedra de Medicina de Familia, Clinical Medicine Department, Miguel Hernandez University, San Juan de Alicante, Spain
| | - Vicente Bertomeu-Gonzalez
- Cardiology Department, Hospital of San Juan de Alicante, San Juan De Alicante, Spain.,Clinical Medicine Department, Miguel Hernandez University, San Juan de Alicante, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Fundación para la Investigacion del Hospital Clínico de la Comunidad Valenciana (Fundación INCLIVA), Valencia, Spain
| | - Vicente F Gil-Guillen
- Catedra de Medicina de Familia, Clinical Medicine Department, Miguel Hernandez University, San Juan de Alicante, Spain
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Abstract
PURPOSE OF REVIEW Multiple experimental and clinical studies have identified pathways by which uric acid may facilitate the development and progression of chronic kidney disease (CKD) in people with diabetes. However, it remains uncertain if the association of uric acid with CKD represents a pathogenic effect or merely reflects renal impairment. RECENT FINDINGS In contrast to many published reports, a recent Mendelian randomization study did not identify a causal link between uric acid and CKD in people with type 1 diabetes. Two recent multicenter randomized control trials, Preventing Early Renal Function Loss in Diabetes (PERL) and FEbuxostat versus placebo rAndomized controlled Trial regarding reduced renal function in patients with Hyperuricemia complicated by chRonic kidney disease stage 3 (FEATHER), were recently designed to assess if uric acid lowering slows progression of CKD. We review the evidence supporting a role for uric acid in the pathogenesis of CKD in people with diabetes and the putative benefits of uric acid lowering.
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Affiliation(s)
- Ambreen Gul
- Dialysis Clinic, Inc., Quality Management, 1500 Indian School Rd. NE, Albuquerque, NM, 87102, USA
| | - Philip Zager
- Dialysis Clinic, Inc., Quality Management, 1500 Indian School Rd. NE, Albuquerque, NM, 87102, USA.
- University of New Mexico, Albuquerque, NM, USA.
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27
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Desai RJ, Franklin JM, Spoendlin-Allen J, Solomon DH, Danaei G, Kim SC. An evaluation of longitudinal changes in serum uric acid levels and associated risk of cardio-metabolic events and renal function decline in gout. PLoS One 2018; 13:e0193622. [PMID: 29489919 PMCID: PMC5831471 DOI: 10.1371/journal.pone.0193622] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 02/14/2018] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Gout patients have a high burden of co-morbid conditions including diabetes mellitus (DM), chronic kidney disease (CKD), and cardiovascular disease (CVD). We sought to evaluate the association between changes in serum uric acid (SUA) levels over time and the risk of incident DM, CVD, and renal function decline in gout patients. METHODS An observational cohort study was conducted among enrollees of private health insurance programs in the US between 2004 and 2015. Gout patients were included on the index date of a SUA measurement ≥6.8 mg/dl. The exposure of interest was cumulative change in SUA levels from baseline. Hazard ratios (HR) and 95% confidence intervals (CI) for incident DM, incident CVD, and renal function decline (≥30% reduction in glomerular filtration rate) were derived using marginal structural models with stabilized inverse probability weights accounting for baseline confounders (age, gender, co-morbidities, co-medications) and time-varying confounders (serum creatinine, blood urea nitrogen, glycated hemoglobin). RESULTS Among 26,341 patients with gout, the average age was 62, 75% were men, and the median baseline SUA was 8.6 mg/dl (interquartile range 7.7 to 9.5). The incidence rates/100 person-years (95% CI) were 1.63 (1.51-1.75) for DM, 0.77 (0.70-0.84) for CVD, and 4.32 (4.14-4.49) for renal function decline. The adjusted HR (95% CI) per 3 mg/dl reduction in SUA, corresponding on average to achieving the target level of <6 mg/dl in this population, was 1.04 (0.92-1.17) for DM, 1.07 (0.89-1.29) for CVD, and 0.85 (0.78-0.92) for renal function decline. CONCLUSIONS Reduction in SUA in patients with gout may be associated with a reduced risk of renal function decline, but not with DM or CVD.
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Affiliation(s)
- Rishi J. Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital & Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - Jessica M. Franklin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital & Harvard Medical School, Boston, Massachusetts, United States of America
| | - Julia Spoendlin-Allen
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital & Harvard Medical School, Boston, Massachusetts, United States of America
| | - Daniel H. Solomon
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital & Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Goodarz Danaei
- Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Seoyoung C. Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital & Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
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Srivastava A, Kaze AD, McMullan CJ, Isakova T, Waikar SS. Uric Acid and the Risks of Kidney Failure and Death in Individuals With CKD. Am J Kidney Dis 2017; 71:362-370. [PMID: 29132945 DOI: 10.1053/j.ajkd.2017.08.017] [Citation(s) in RCA: 155] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Accepted: 08/10/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Serum uric acid concentrations increase in chronic kidney disease (CKD) and may lead to tubular injury, endothelial dysfunction, oxidative stress, and intrarenal inflammation. Whether uric acid concentrations are associated with kidney failure and death in CKD is unknown. STUDY DESIGN Prospective observational cohort study. SETTINGS & PARTICIPANTS 3,885 individuals with CKD stages 2 to 4 enrolled in the Chronic Renal Insufficiency Cohort (CRIC) between June 2003 and September 2008 and followed up through March 2013. PREDICTOR Baseline uric acid concentrations. OUTCOMES Kidney failure (initiation of dialysis therapy or transplantation) and all-cause mortality. RESULTS During a median follow-up of 7.9 years, 885 participants progressed to kidney failure and 789 participants died. After adjustment for demographic, cardiovascular, and kidney-specific covariates, higher uric acid concentrations were independently associated with risk for kidney failure in participants with estimated glomerular filtration rates (eGFRs) ≥ 45mL/min/1.73m2 (adjusted HR per 1-standard deviation greater baseline uric acid, 1.40; 95% CI, 1.12-1.75), but not in those with eGFRs<30mL/min/1.73m2. There was a nominally higher HR in participants with eGFRs of 30 to 44mL/min/1.73m2 (adjusted HR, 1.13; 95% CI, 0.99-1.29), but this did not reach statistical significance. The relationship between uric acid concentration and all-cause mortality was J-shaped (P=0.007). LIMITATIONS Potential residual confounding through unavailable confounders; lack of follow-up measurements to adjust for changes in uric acid concentrations over time. CONCLUSIONS Uric acid concentration is an independent risk factor for kidney failure in earlier stages of CKD and has a J-shaped relationship with all-cause mortality in CKD. Adequately powered randomized placebo-controlled trials in CKD are needed to test whether urate lowering may prove to be an effective approach to prevent complications and progression of CKD.
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Affiliation(s)
- Anand Srivastava
- Renal Division, Brigham & Women's Hospital, Boston, MA; Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Arnaud D Kaze
- Renal Division, Brigham & Women's Hospital, Boston, MA
| | | | - Tamara Isakova
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
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Abstract
AIMS Elevated serum uric acid (SUA) is often present in conditions associated with increased cardiovascular risk yet it is not recognized as a marker of risk. We evaluated whether SUA was associated with evidence of early markers of cardiovascular risk factor including subclinical early organ damage, sympathetic tone and metabolic profile in a healthy population with a high prevalence of obesity. MATERIAL AND METHODS Data from 281 patients (175 women and 106 men, mean age: 35.5 ± 0.8 years, mean BMI: 33.2 ± 0.5 kg/m) were retrieved from a database. All participants were healthy, nonsmoker and free of medication. Available data included metabolic profile, muscle sympathetic nervous activity (MSNA, microneurography), endothelial function (pulse amplitude tonometry, augmentation index), estimated glomerular filtration rate (eGFR) and echocardiography. RESULTS With participants grouped into sex-adjusted tertiles of SUA, those in the third tertile of SUA had increased waist circumference, worse metabolic profile (fasting glucose, total cholesterol, triglycerides and HDL), elevated MSNA, decreased endothelial function, increased augmentation index and decreased eGFR compared with those in the first tertile of SUA. In multiple regression analysis adjusted for age, sex, BMI and ethnicity, SUA was independently associated with waist circumference, low-density lipoprotein, triglycerides, augmentation index, MSNA and eGFR, providing a combined adjusted R = 0.599 or 60% of the overall variance. CONCLUSION In a healthy population with a high proportion of obesity, SUA is associated with measures of metabolic, end-organ damage and sympathetic tone indicating the potential value of SUA as a marker of early cardiovascular disease development.
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Xanthine oxidoreductase and its inhibitors: relevance for gout. Clin Sci (Lond) 2017; 130:2167-2180. [PMID: 27798228 DOI: 10.1042/cs20160010] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 09/14/2016] [Indexed: 12/22/2022]
Abstract
Xanthine oxidoreductase (XOR) is the rate-limiting enzyme in purine catabolism and converts hypoxanthine to xanthine, and xanthine into uric acid. When concentrations of uric acid exceed its biochemical saturation point, crystals of uric acid, in the form of monosodium urate, emerge and can predispose an individual to gout, the commonest form of inflammatory arthritis in men aged over 40 years. XOR inhibitors are primarily used in the treatment of gout, reducing the formation of uric acid and thereby, preventing the formation of monosodium urate crystals. Allopurinol is established as first-line therapy for gout; a newer alternative, febuxostat, is used in patients unable to tolerate allopurinol. This review provides an overview of gout, a detailed analysis of the structure and function of XOR, discussion on the pharmacokinetics and pharmacodynamics of XOR inhibitors-allopurinol and febuxostat, and the relevance of XOR in common comorbidities of gout.
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Abstract
Gout, an inflammatory arthritis caused by the deposition of monosodium urate crystals, is commonly seen in primary care and specialist clinics. In recent years, there has been a resurgence of interest in gout due to advances in therapies and the understanding of pathophysiology, with new guidelines being published by international bodies. However, there is still a gap between the goals of treatment and actual day-to-day practice. Barriers that result in poorly controlled gout include patient factors such as lack of understanding of the disease, stigma and nonadherence to treatment, as well as physician factors such as knowledge gaps, inadequate use of allopurinol and lack of ownership of the disease. The medical profession needs to do more to bridge the gap through physician and patient education, identification of treatment targets with appropriate use of drugs, and dissemination of guidelines.
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Hui M, Carr A, Cameron S, Davenport G, Doherty M, Forrester H, Jenkins W, Jordan KM, Mallen CD, McDonald TM, Nuki G, Pywell A, Zhang W, Roddy E. The British Society for Rheumatology Guideline for the Management of Gout. Rheumatology (Oxford) 2017; 56:e1-e20. [DOI: 10.1093/rheumatology/kex156] [Citation(s) in RCA: 119] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Indexed: 12/13/2022] Open
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Singh JA, Cleveland JD. Comparative effectiveness of allopurinol versus febuxostat for preventing incident renal disease in older adults: an analysis of Medicare claims data. Ann Rheum Dis 2017; 76:1669-1678. [PMID: 28584186 DOI: 10.1136/annrheumdis-2017-211210] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 04/24/2017] [Accepted: 04/30/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess the comparative effectiveness of allopurinol versus febuxostat for preventing incident renal disease in elderly. METHODS In a retrospective cohort study using 2006-2012 Medicare claims data, we included patients newly treated with allopurinol or febuxostat (baseline period of 183 days without either medication). We used 5:1 propensity-matched Cox regression analyses to compare the HR of incident renal disease with allopurinol use (and dose) versus febuxostat (reference). Sensitivity analyses included multivariable-adjusted regression models. RESULTS There were 31 465 new allopurinol or febuxostat treatment episodes in 26 443 patients; 8570 ended in incident renal disease. Crude rates of incident renal disease per 1000 person-years were 192 with allopurinol versus 338 with febuxostat. Crude rates of incident renal disease per 1000 person-years were lower with higher daily dose: allopurinol <200, 200-299 and ≥300 mg/day with 238, 176 and 155; and febuxostat 40 and 80 mg/day with 341 and 326, respectively. In propensity-matched analyses, compared with febuxostat, allopurinol use was associated with lower HR of incident renal disease, 0.61 (95% CI 0.49 to 0.77). Compared with febuxostat 40 mg/day, allopurinol doses <200, 200-299 and ≥300 mg/day were associated with lower HR of incident renal disease, 0.75 (95% CI 0.65 to 0.86), 0.61 (95% CI 0.52 to 0.73) and 0.48 (95% CI 0.41 to 0.55), respectively. Sensitivity analyses using multivariable-adjusted regression confirmed these findings. CONCLUSIONS Allopurinol was associated with a lower risk of incident renal disease in elderly patients than febuxostat. Future studies need to examine the mechanism of this potential renal benefit of allopurinol.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service, VA Medical Center, Birmingham, Alabama, USA.,Department of Medicine at School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Division of Epidemiology at School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - John D Cleveland
- Department of Medicine at School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Yamaguchi A, Harada M, Yamada Y, Hashimoto K, Kamijo Y. Identification of chronic kidney disease patient characteristics influencing the renoprotective effects of febuxostat therapy: a retrospective follow-up study. BMC Nephrol 2017; 18:162. [PMID: 28521802 PMCID: PMC5437587 DOI: 10.1186/s12882-017-0572-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 05/03/2017] [Indexed: 12/12/2022] Open
Abstract
Background The ability of antihyperuricemic therapy to exert renoprotective effects in patients with chronic kidney disease (CKD) is controversial. In the present study, we studied patient characteristics that may mask favorable impact of antihyperuricemic therapy on the progression of CKD. Methods This was a single-center, retrospective, follow-up study. One-hundred and seventy-eight CKD patients with hyperuricemia who received febuxostat therapy were included in this study. Mean serum uric acid (mUA) level after treatment and changes in estimated glomerular filtration rate (ΔeGFR) over 6 months were measured and their correlation was examined. Patients were divided into two groups based on mUA, and their ΔeGFR were compared. These analyses were evaluated in various subgroups. Results Febuxostat therapy markedly decreased UA level in any CKD stage patients without resulting in serious adverse events. eGFRs of CKD patients in the mUA < 6.0 mg/dl group were maintained, whereas those in the mUA ≥ 6.0 mg/dl group decreased. A significant inverse correlation was observed between mUA and ΔeGFR (r = −0.16, p = 0.019). The renoprotective effects of febuxostat were significant in the following subgroups: male patients, age < 70 years, systolic blood pressure < 130 mmHg, normal cholesterol levels, and absence of diabetes. Coexisting vascular risk factors appear to exert additive masking effects against febuxostat renoprotection. Conclusions The results of this study suggest that various vascular risk factors markedly attenuate the renoprotective effects of febuxostat. Electronic supplementary material The online version of this article (doi:10.1186/s12882-017-0572-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Akinori Yamaguchi
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Makoto Harada
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Yosuke Yamada
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Koji Hashimoto
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Yuji Kamijo
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan.
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Liu CT, Chen CY, Hsu CY, Huang PH, Lin FY, Chen JW, Lin SJ. Risk of Febuxostat-Associated Myopathy in Patients with CKD. Clin J Am Soc Nephrol 2017; 12:744-750. [PMID: 28302902 PMCID: PMC5477209 DOI: 10.2215/cjn.08280816] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 02/08/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Febuxostat, a nonpurine xanthine oxidase inhibitor, is widely used to treat hyperuricemia. Although febuxostat-associated rhabdomyolysis was reported in some patients with CKD, the association between CKD and febuxostat-associated myopathy remains uncertain. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Our retrospective cohort study included 1332 patients using febuxostat in Taipei Medical University-Wanfang Hospital from February of 2014 to January of 2016. The primary predictor was time-averaged eGFR as calculated by the equation proposed by the 2009 Chronic Kidney Disease Epidemiology Collaboration. The outcome was febuxostat-associated myopathy defined as elevated creatine kinase levels during febuxostat use that were not attributed to other muscular injuries. RESULTS The median duration of febuxostat use was 224 days (25th, 75th percentiles: 86, 441.5 days). Of 1332 study participants, 1222 (91.7%) had CKD; the median eGFR was 20.8 ml/min per 1.73 m2 (25th, 75th percentiles: 9.0, 35.4 ml/min per 1.73 m2). Forty-one of the participants had febuxostat-associated myopathy (3.2%). All patients with myopathy had CKD, and the incident rate was 0.013 (95% confidence interval, 0.01 to 0.02) events per 100 patient-days in patients with CKD. Of 41 patients with myopathy, 37 had myositis, and four had rhabdomyolysis. Myopathy resolved in 17 patients who withdrew from treatment and eight patients who continued febuxostat treatment. Among the evaluated predictors, multivariate analysis showed that only the lowest eGFR tertile was significantly associated with myopathy in febuxostat users. The odds ratio of the lowest eGFR tertile to the highest tertile was 4.21 (95% confidence interval, 1.7 to 10.43). This finding remained consistent among subgroups stratified by age, sex, diabetes status, coronary artery disease, and statin or fibrate use. CONCLUSIONS Patients with severely reduced eGFR had higher risk of myopathy with treatment of febuxostat. Regular monitoring of creatine kinase level is suggested for early detection of febuxostat-associated myopathy, particularly in patients with CKD.
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Affiliation(s)
- Chung-te Liu
- Division of Nephrology, Department of Internal Medicine, Wanfang Hospital
- Department of Internal Medicine, School of Medecine, College of Medicine and
| | - Chun-You Chen
- Department of Radiation Oncology, Wan Fang Hospital, and
| | - Chien-Yi Hsu
- Department of Internal Medicine, School of Medecine, College of Medicine and
- Institutes of Clinical Medicine and
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
- Division of Cardiology and Cardiovascular Research Center, Department of Internal Medicine, Taipei Medical University–Hospital Taipei, Taipei, Taiwan; and
| | - Po-Hsun Huang
- Institutes of Clinical Medicine and
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
- Division of Cardiology, Department of Medicine and
| | - Feng-Yen Lin
- Department of Internal Medicine, School of Medecine, College of Medicine and
- Division of Cardiology and Cardiovascular Research Center, Department of Internal Medicine, Taipei Medical University–Hospital Taipei, Taipei, Taiwan; and
| | - Jaw-Wen Chen
- Pharmacology and
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
- Division of Cardiology, Department of Medicine and
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shing-Jong Lin
- Board of Directors, Taipei Medical University, Taipei, Taiwan
- Institutes of Clinical Medicine and
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
- Division of Cardiology, Department of Medicine and
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
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Vargas-Santos AB, Neogi T. Management of Gout and Hyperuricemia in CKD. Am J Kidney Dis 2017; 70:422-439. [PMID: 28456346 DOI: 10.1053/j.ajkd.2017.01.055] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 01/21/2017] [Indexed: 02/07/2023]
Abstract
Hyperuricemia and gout, the clinical manifestation of monosodium urate crystal deposition, are common in patients with chronic kidney disease (CKD). Although the presence of CKD poses additional challenges in gout management, effective urate lowering is possible for most patients with CKD. Initial doses of urate-lowering therapy are lower than in the non-CKD population, whereas incremental dose escalation is guided by regular monitoring of serum urate levels to reach the target level of <6mg/dL (or <5mg/dL for patients with tophi). Management of gout flares with presently available agents can be more challenging due to potential nephrotoxicity and/or contraindications in the setting of other common comorbid conditions. At present, asymptomatic hyperuricemia is not an indication for urate-lowering therapy, though emerging data may support a potential renoprotective effect.
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Affiliation(s)
| | - Tuhina Neogi
- Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, MA.
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Asymptomatic hyperuricemia is a strong risk factor for resistant hypertension in elderly subjects from general population. Biomed Pharmacother 2016; 86:590-594. [PMID: 28027534 DOI: 10.1016/j.biopha.2016.11.104] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 11/24/2016] [Accepted: 11/27/2016] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE In clinical practice, patient characteristics predicting resistant hypertension (RH) include higher blood pressure levels, left ventricular hypertrophy, older age, obesity, chronic kidney disease and diabetes. On the contrary little is known about the role of serum uric acid (SUA) as a risk factor for RH in subjects from general population. MATERIAL AND METHODS 580 elderly subjects aged ≥65 years were enrolled in the Risk Of Vascular complications Impact of Genetics in Old people (ROVIGO) study. RH was defined as the failure to maintain blood pressure values below 140mmHg (systolic) and 90mmHg (diastolic) despite therapeutic interventions that include appropriate lifestyle measures plus adherence to treatment with full doses of at least three antihypertensive drugs, including a diuretic. RH was confirmed using 24-h ambulatory blood pressure measurement. Hyperuricemic was defined as the subjects having SUA ≥6.8mg/dl or taking uricosuric drugs. Gender-specific odds ratio (OR) for RH was calculated by logistic regression analysis. RESULTS The prevalence of RH was 5.7% in the cohort and was higher in women (8.3%) than in men (3.0%, p<0.05). Independent of chronic kidney disease (OR 3.89, 95% confidence interval 1.49-10.1), hyperuricemia predicted resistant hypertension in women (odds ratio 3.11, 95% confidence intervals 1.06-9.1, p=0.03) but not in men. CONCLUSIONS In elderly women from the general population, an SUA value of ≥6.8mg/dl triples the risk of RH. SUA assessment should be recommended to better define the pattern of risk associated with RH.
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Kaminska-Pajak KA, Dyga K, Adamczyk P, Szczepańska M, Zaniew M, Beck B, Tkaczyk M. Familial juvenile hyperuricemic nephropathy as rare cause of dialysis-dependent chronic kidney disease-a series of cases in two families. Ren Fail 2016; 38:1759-1762. [PMID: 27764983 DOI: 10.1080/0886022x.2016.1229991] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Hyperuricemia is a common symptom in adult population. It usually accompanies the chronic kidney disease. Less frequently, it is a primary phenomenon causing later serious clinical consequences. Familial juvenile hyperuricemic nephropathy (FJHN) is one of the hereditary conditions associated with high levels of serum uric acid and leading to dialysis in young adult age. It results from mutation in the UMOD gene, encoding the uromodulin protein, that is, Tamm-Horsfall protein. The aim of this paper was to present two families (7 affected members) with FJHN, in whom standard nephrological diagnostics did not provide clear cause of dialysis-dependent chronic kidney disease, until genetic testing was performed.
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Affiliation(s)
- Kamila A Kaminska-Pajak
- a Department of Pediatrics, Immunology and Nephrology , Polish Mother's Memorial Hospital Research Institute , Lodz , Poland
| | - Katarzyna Dyga
- b Department of Pediatric Nephrology with Dialysis Division , SPSK no 1 , Zabrze , Poland
| | - Piotr Adamczyk
- c Chair and Department of Pediatrics , Silesian Medical University , Katowice , Poland
| | - Maria Szczepańska
- c Chair and Department of Pediatrics , Silesian Medical University , Katowice , Poland
| | | | - Bodo Beck
- e Institute of Human Genetics, University of Cologne , Cologne , Poland
| | - Marcin Tkaczyk
- a Department of Pediatrics, Immunology and Nephrology , Polish Mother's Memorial Hospital Research Institute , Lodz , Poland.,f IV Chair of Pediatrics, Medical University of Lodz , Lodz , Poland
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Effects of uric-acid-lowering therapy on renal outcomes: the future looks promising. Hypertens Res 2016; 39:578-80. [DOI: 10.1038/hr.2016.52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Singh JA, Yu S. Are allopurinol dose and duration of use nephroprotective in the elderly? A Medicare claims study of allopurinol use and incident renal failure. Ann Rheum Dis 2016; 76:133-139. [PMID: 27296322 DOI: 10.1136/annrheumdis-2015-209046] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 04/17/2016] [Accepted: 04/24/2016] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To assess the effect of allopurinol dose/duration on the risk of renal failure in the elderly with allopurinol use. METHODS We used the 5% random Medicare claims data from 2006 to 2012. Multivariable-adjusted Cox regression analyses assessed the association of allopurinol dose/duration with subsequent risk of developing incident renal failure or end-stage renal disease (ESRD) (no prior diagnosis in last 183 days) in allopurinol users, controlling for age, sex, race and Charlson-Romano comorbidity index. HRs with 95% CIs were calculated. Sensitivity analyses considered a longer baseline period (365 days), controlled for gout or used more specific codes. RESULTS Among the 30 022 allopurinol treatment episodes, 8314 incident renal failure episodes occurred. Compared with 1-199 mg/day, allopurinol dose of 200-299 mg/day (HR 0.81; 95% CI 0.75 to 0.87) and ≥300 mg/day, 0.71 (0.67 to 0.76), had significantly lower hazard of renal failure in multivariable-adjustment model, confirmed in multiple sensitivity analyses. Longer allopurinol use duration was significantly associated with lower hazards in sensitivity analyses (365-day look-back; reference, <0.5 year): 0.5-1 year, 1.00 (0.88, 1.15); >1-2 years, 0.85 (0.73 to 0.99); and >2 years, 0.81 (0.67 to 0.98). Allopurinol ≥300 mg/day was also associated with significantly lower risk of acute renal failure and ESRD with HR of 0.89 (0.83 to 0.94) and 0.57 (0.46 to 0.71), respectively. CONCLUSIONS Higher allopurinol dose is independently protective against incident renal failure in the elderly allopurinol users. A longer duration of allopurinol use may be associated with lower risk of incident renal failure. Potential mechanisms of these effects need to be examined.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service, Birmingham VA Medical Center, Birmingham, Alabama, USA.,Division of Epidemiology, Department of Medicine School of Medicine, School of Public Health, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA.,Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Shaohua Yu
- Division of Epidemiology, Department of Medicine School of Medicine, School of Public Health, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
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Serum uric acid and the risk of cardiovascular and renal disease. J Hypertens 2016; 33:1729-41; discussion 1741. [PMID: 26136207 DOI: 10.1097/hjh.0000000000000701] [Citation(s) in RCA: 320] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Substantial evidence suggests that chronic hyperuricemia is an independent risk factor for hypertension, metabolic syndrome, chronic kidney disease (CKD) and cardiovascular diseases. This highlights the need for greater attention to serum uric acid levels when profiling patients, and suggests that the threshold above which uricemia is considered abnormal is 6 mg/dl, in light of the available evidence. Another important question is whether lowering serum uric acid can improve cardiovascular and renal outcomes, and what therapeutic mechanism of action could provide more clinical benefits to patients; the available literature shows a trend toward improvement associated with administration of urate-lowering drugs, in particular for the xanthine oxidase inhibitors. The demonstrated efficacy of urate-lowering therapy on outcomes other than gout flares leads to the consideration that treatment may be beneficial even in the absence of overt gout when hyperuricemia accompanies other clinical conditions, such as urate deposition, advanced CKD or cardiovascular risk factors.
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Levy G, Cheetham TC. Is It Time to Start Treating Asymptomatic Hyperuricemia? Am J Kidney Dis 2016; 66:933-5. [PMID: 26593311 DOI: 10.1053/j.ajkd.2015.09.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Accepted: 09/04/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Gerald Levy
- Southern California Permanente Medical Group, Downey, California.
| | - T Craig Cheetham
- Southern California Permanente Medical Group, Pasadena, California
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Abstract
Chronic kidney disease (CKD) is associated with significant morbidity and mortality, impacted not alone by progression to end-stage kidney disease, but also by the high associated incidence of cardiovascular events and related mortality. Despite our current understanding of the pathogenesis of CKD and the treatments available, the reported incidence of CKD continues to rise worldwide, and is often referred to as the silent public healthcare epidemic. The significant cost to patient wellbeing and to the economy of managing the later stages of CKD have prompted efforts to develop interventions to delay the development and progression of this syndrome. In this article, we review established and novel agents that may aid in delaying the progression of CKD and improve patient outcomes.
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Affiliation(s)
- Frank Ward
- St Vincent's University Hospital, Dublin 4, Ireland
| | - John Holian
- St Vincent's University Hospital, Dublin 4, Ireland
| | - Patrick T Murray
- School of Medicine, University College Dublin, Health Sciences Centre, Dublin 4, Ireland
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Kim Y, Shin S, Kim K, Choi S, Lee K. Effect of Urate Lowering Therapy on Renal Disease Progression in Hyperuricemic Patients with Chronic Kidney Disease. J Rheumatol 2015; 42:2143-8. [PMID: 26428209 DOI: 10.3899/jrheum.150067] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine whether urate lowering therapy (ULT) could delay renal disease progression in hyperuricemic patients with chronic kidney disease (CKD). METHODS We performed a retrospective review of hyperuricemic patients with stage 3 CKD followed from September 2005 to July 2014 in Dongguk University Ilsan Hospital, Goyang, Korea. A total of 158 eligible patients were identified and 65 of them were treated with ULT in addition to the usual CKD management. We divided the patients according to the use of ULT and compared the estimated glomerular filtration rate (eGFR) change from baseline value and the proportion of renal disease progression (decline of eGFR > 30% of the baseline value, initiation of dialysis or eGFR < 15 ml/min/1.73m(2)) at the time of last followup. Risk factors for renal disease progression were identified by logistic regression analysis. RESULTS After a median followup of 118.5 weeks (minimum 25, maximum 465), the ULT group showed better outcomes compared to the non-ULT group in terms of eGFR change from baseline (-1.19 ± 12.07 vs -7.37 ± 11.17 ml/min/1.73 m(2), p = 0.001) and the proportion of renal disease progression (12.3% vs 27.9%, p = 0.01). Goal-directed ULT showed better clinical outcomes compared to maintaining the initial ULT dose. Actual (area under the SUA-time curve adjusted by total observation time period) serum uric acid was significantly associated with the risk of renal disease progression (p for trend = 0.04) and actual serum uric acid level < 7 mg/dl reduced the risk of renal disease progression by 69.4%. CONCLUSION ULT significantly delayed renal disease progression in hyperuricemic patients with CKD. Goal-directed ULT seems to be better than continuing the initial ULT prescription.
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Affiliation(s)
- Yoonjin Kim
- From the Division of Nephrology and the Division of Rheumatology, Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang; and the Division of Rheumatology, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, South Korea.Y. Kim, MD, Research Fellow, Division of Nephrology, Department of Internal Medicine, Dongguk University Ilsan Hospital; S. Shin, MD, PhD, Associate Professor, Division of Nephrology, Department of Internal Medicine, Dongguk University Ilsan Hospital; K. Kim, MD, PhD, Professor, Division of Nephrology, Department of Internal Medicine, Dongguk University Ilsan Hospital; S. Choi, MD, Assistant Professor, Division of Rheumatology, Department of Internal Medicine, Chung-Ang University College of Medicine; K. Lee, MD, Assistant Professor, Division of Rheumatology, Department of Internal Medicine, Dongguk University Ilsan Hospital
| | - Sungjoon Shin
- From the Division of Nephrology and the Division of Rheumatology, Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang; and the Division of Rheumatology, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, South Korea.Y. Kim, MD, Research Fellow, Division of Nephrology, Department of Internal Medicine, Dongguk University Ilsan Hospital; S. Shin, MD, PhD, Associate Professor, Division of Nephrology, Department of Internal Medicine, Dongguk University Ilsan Hospital; K. Kim, MD, PhD, Professor, Division of Nephrology, Department of Internal Medicine, Dongguk University Ilsan Hospital; S. Choi, MD, Assistant Professor, Division of Rheumatology, Department of Internal Medicine, Chung-Ang University College of Medicine; K. Lee, MD, Assistant Professor, Division of Rheumatology, Department of Internal Medicine, Dongguk University Ilsan Hospital
| | - Kyungsoo Kim
- From the Division of Nephrology and the Division of Rheumatology, Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang; and the Division of Rheumatology, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, South Korea.Y. Kim, MD, Research Fellow, Division of Nephrology, Department of Internal Medicine, Dongguk University Ilsan Hospital; S. Shin, MD, PhD, Associate Professor, Division of Nephrology, Department of Internal Medicine, Dongguk University Ilsan Hospital; K. Kim, MD, PhD, Professor, Division of Nephrology, Department of Internal Medicine, Dongguk University Ilsan Hospital; S. Choi, MD, Assistant Professor, Division of Rheumatology, Department of Internal Medicine, Chung-Ang University College of Medicine; K. Lee, MD, Assistant Professor, Division of Rheumatology, Department of Internal Medicine, Dongguk University Ilsan Hospital
| | - Sangtae Choi
- From the Division of Nephrology and the Division of Rheumatology, Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang; and the Division of Rheumatology, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, South Korea.Y. Kim, MD, Research Fellow, Division of Nephrology, Department of Internal Medicine, Dongguk University Ilsan Hospital; S. Shin, MD, PhD, Associate Professor, Division of Nephrology, Department of Internal Medicine, Dongguk University Ilsan Hospital; K. Kim, MD, PhD, Professor, Division of Nephrology, Department of Internal Medicine, Dongguk University Ilsan Hospital; S. Choi, MD, Assistant Professor, Division of Rheumatology, Department of Internal Medicine, Chung-Ang University College of Medicine; K. Lee, MD, Assistant Professor, Division of Rheumatology, Department of Internal Medicine, Dongguk University Ilsan Hospital
| | - Kwanghoon Lee
- From the Division of Nephrology and the Division of Rheumatology, Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang; and the Division of Rheumatology, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, South Korea.Y. Kim, MD, Research Fellow, Division of Nephrology, Department of Internal Medicine, Dongguk University Ilsan Hospital; S. Shin, MD, PhD, Associate Professor, Division of Nephrology, Department of Internal Medicine, Dongguk University Ilsan Hospital; K. Kim, MD, PhD, Professor, Division of Nephrology, Department of Internal Medicine, Dongguk University Ilsan Hospital; S. Choi, MD, Assistant Professor, Division of Rheumatology, Department of Internal Medicine, Chung-Ang University College of Medicine; K. Lee, MD, Assistant Professor, Division of Rheumatology, Department of Internal Medicine, Dongguk University Ilsan Hospital.
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Testa A, Mallamaci F, Leonardis D, Spoto B, Pisano A, Sanguedolce MC, Tripepi G, Zoccali C. Synergism between asymmetric dimethylarginine (ADMA) and a genetic marker of uric acid in CKD progression. Nutr Metab Cardiovasc Dis 2015; 25:167-172. [PMID: 25435339 DOI: 10.1016/j.numecd.2014.10.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 09/25/2014] [Accepted: 10/27/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND & AIMS We have recently reported that a polymorphism (rs734553) in a major urate transporter gene (GLUT9) is a strong predictor of incident renal events in stage 2-5 CKD patients implying that life-time exposure to high uric acid levels may be causally implicated in CKD progression. Since disturbed NO bioavailability is a major pathway whereby high uric may cause renal damage, we tested the interaction between the major endogenous inhibitor of NO synthase, asymmetric-dimethylargine (ADMA), and the rs734553 polymorphism for CKD progression in the same cohort. METHODS & RESULTS Over a 29 ± 11 months follow-up the risk for incident renal events was higher in patients harboring the risk allele of the polymorphism (T) as compared to those without the risk allele (HR: 2.35, 95% CI: 1.25-4.42, P = 0.008) (p = 0.01). Similarly, patients with ADMA > median value had an increased risk for the same outcome (HR: 1.37, 95% CI: 1.06-1.76, P = 0.016). Interaction analysis showed a strong amplification by ADMA of the risk for renal events associated to the T allele because in adjusted (P = 0.016) and bootstrapping validated (P = 0.020) analyses the risk excess associated to this allele was progressively higher across increasing ADMA levels. CONCLUSIONS The rs734553 polymorphism, the strongest genetic marker of uric acid levels discovered so far, interacts with ADMA in determining the risk for CKD progression in CKD patients. This synergic interaction conforms to biological knowledge indicating that disturbed NO bio-availability is a critical pathway whereby life time exposure to high uric acid may engender renal damage.
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Affiliation(s)
- A Testa
- CNR-IFC/IBIM, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Ospedali Riuniti, 89124 Reggio Calabria, Italy
| | - F Mallamaci
- CNR-IFC/IBIM, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Ospedali Riuniti, 89124 Reggio Calabria, Italy
| | - D Leonardis
- CNR-IFC/IBIM, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Ospedali Riuniti, 89124 Reggio Calabria, Italy
| | - B Spoto
- CNR-IFC/IBIM, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Ospedali Riuniti, 89124 Reggio Calabria, Italy
| | - A Pisano
- CNR-IFC/IBIM, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Ospedali Riuniti, 89124 Reggio Calabria, Italy
| | - M C Sanguedolce
- CNR-IFC/IBIM, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Ospedali Riuniti, 89124 Reggio Calabria, Italy
| | - G Tripepi
- CNR-IFC/IBIM, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Ospedali Riuniti, 89124 Reggio Calabria, Italy
| | - C Zoccali
- CNR-IFC/IBIM, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Ospedali Riuniti, 89124 Reggio Calabria, Italy.
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Abstract
A bulk of evidence now exists that links gout with adverse cardiovascular (CV) outcomes. However, continuing doubt remains as to whether hyperuricemia can be truly considered an independent major CV risk factor. In fact, many gouty patients who develop major CV and renal events also possess several traditional CV risk factors, the presence of which can potentially confound any relationship between gout and adverse CV events. This paper reviews the available evidence to determine whether sufficient proof exists from biological, epidemiological and clinical trial studies to support a causal relationship between gout and major CV and renal events. This review is based on a PubMed/Embase database search for articles on hyperuricemia and its impact on cardiovascular and renal function.
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Affiliation(s)
- A Stack
- a a University Hospital Limerick, Graduate Entry Medical School, University of Limerick , Ireland
| | - A J Manolis
- b b Cardiology Dept , Asklepeion General Hospital , Athens , Greece
| | - E Ritz
- c c Department of Nephrology , Nierenzentrum , Heidelberg , Germany
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Jing J, Kielstein JT, Schultheiss UT, Sitter T, Titze SI, Schaeffner ES, McAdams-DeMarco M, Kronenberg F, Eckardt KU, Kottgen A, for the GCKD Study Investigators, Eckardt KU, Titze S, Prokosch HU, Barthlein B, Reis A, Ekici AB, Gefeller O, Hilgers KF, Hubner S, Avendano S, Becker-Grosspitsch D, Hauck N, Seuchter SA, Hausknecht B, Rittmeier M, Weigel A, Beck A, Ganslandt T, Knispel S, Dressel T, Malzer M, Floege J, Eitner F, Schlieper G, Findeisen K, Arweiler E, Ernst S, Unger M, Lipski S, Schaeffner E, Baid-Agrawal S, Petzold K, Schindler R, Kottgen A, Schultheiss U, Meder S, Mitsch E, Reinhard U, Walz G, Haller H, Lorenzen J, Kielstein JT, Otto P, Sommerer C, Follinger C, Zeier M, Wolf G, Busch M, Paul K, Dittrich L, Sitter T, Hilge R, Blank C, Wanner C, Krane V, Schmiedeke D, Toncar S, Cavitt D, Schonowsky K, Borner-Klein A, Kronenberg F, Raschenberger J, Kollerits B, Forer L, Schonherr S, Weissensteiner H, Oefner P, Gronwald W, Zacharias H, Schmid M. Prevalence and correlates of gout in a large cohort of patients with chronic kidney disease: the German Chronic Kidney Disease (GCKD) study. Nephrol Dial Transplant 2014; 30:613-21. [DOI: 10.1093/ndt/gfu352] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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