Epidemiology of hyperuricemia and gout

Gout is an increasingly common medical problem. The traditional risk factors of male sex and high red meat or alcohol consumption have been joined by a wave of newer risk factors, such as increased longevity, the metabolic syndrome (hypertension, diabetes, dyslipidemia, truncal obesity, increased cardiovascular disease risk), use of diuretics, low-dose aspirin, or cyclosporine, and end-stage renal disease. Atypical presentations of gout in the elderly can mimic osteoarthritis and rheumatoid arthritis. There is a resurgence of interest in hyperuricemia as an independent and potentially modifiable cardiovascular risk factor. The pharmacologic management of gout in general practice suffers from a number of quality-control issues. This article reviews these and other new epidemiologic data on this ancient disease.

Clinical, humanistic, and economic outcomes of gout

Gout is a low prevalence disease not often considered by managed care organizations with regard to cost management. Understanding the development of the disease and its potential long-term, high-cost consequences can lead to appropriate treatment strategies and cost-management opportunities that can improve patient outcomes and potentially lower the overall cost of treatment of patients with gout in a managed care organization. The acute and chronic nature of the disease is best managed up front to avoid negative long-term effects. Adherence to medications can also impact the manifestation of the disease.

Hyperuricemia as a risk factor on cardiovascular events in Taiwan: The Chin-Shan Community Cardiovascular Cohort Study

Little is known about uric acid role for cardiovascular events in the Asian-Pacific countries with relatively low coronary heart disease (CHD) but high stroke events. Also, there is scanty evidence for repeated measures of uric acid levels among population. We examined associations of basic and repeated measures of uric acid level with CHD and stroke events in one Taiwanese adult community prospectively. Cox proportional hazards models, treating uric acid as baseline and time-dependent covariates, were used to assess the 11-year risk of CHD and stroke events. Among 3602 adult subjects older than 35 years, 86 incident CHD and 155 incident stroke cases were identified. The rate ratios of hyperuricemia ranged between 2.00 and 3.96, with higher risk ratios in women than in men. The rate differences and population attributable fractions were also higher in women than in men, implying that women had high risk of uric acid on cardiovascular events. After adjustment for age effect, time-dependent uric acid was associated with significant CHD risk in both genders (hazard risk [HR] 1.43, 95% CI: 1.10-1.87 in men and HR 1.22, 95% CI: 1.03-1.44 in women). But the magnitude of hazard risks decreased after adjusting more atherosclerotic risk factors for CHD. For stroke event, the age-adjusted hazard risk of time-dependent continuous uric acid level was 1.23 (95% CI: 1.00-1.54) in men and 1.36 (95% CI: 1.05-1.75) in women. Multiple adjustment by risk factors demonstrated that uric acid was still a significant predictor for stroke in women (HR 1.32, 95% CI: 1.00-1.73). The similar hazard risk patterns existed for binary categories of hyperuricemia. Subgroup analyses demonstrated uric acid had significant risk only in hypertension and metabolic syndrome subgroups, not in their counterparts. We concluded that uric acid, in the baseline and time-dependent variables, could predict cardiovascular events in the community of relatively low CHD but high stroke risk in Taiwan.

Hyperuricemia as a predictor of hypertension in a screened cohort in Okinawa, Japan

Several epidemiological studies have shown a positive association between serum uric acid levels and the risk of hypertension. However, subjects in these studies were mostly men, or were incompletely examined for lifestyle-related variables. We prospectively examined the relation between hyperuricemia and the risk of developing hypertension with consideration for alcohol consumption and smoking habits in a large screened cohort of men and women. A total of 4,489 individuals (2,927 men and 1,562 women) who did not have hypertension and were not currently using antihypertensive medication were examined at the Okinawa General Health Maintenance Association in 1977. Subjects were re-examined in 2000. Hyperuricemia was defined as a serum uric acid level >or=7.0 mg/dl in men and >or=6.0 mg/dl in women. Hypertension was defined as systolic blood pressure (SBP) >or=140 mmHg, and/or diastolic blood pressure (DBP) >or=90 mmHg. A total of 289 subjects (201 men and 88 women) were hypertensive (SBP >or=140 mmHg, and/or DBP >or=90 mmHg) in 2000. Multivariate analysis was performed for development of hypertension in hyperuricemic subjects, adjusted for age, family history of hypertension, alcohol consumption, cigarette smoking, obesity, hypercholesterolemia, hypertriglyceridemia, low high-density lipoprotein cholesterol, and diabetes mellitus. The adjusted odds ratio (95% confidence interval) in men was 1.48 (1.08-2.02) and in women was 1.90 (1.03-3.51) (p <0.05, respectively). The results showed hyperuricemia to be a new predictor of hypertension development in both men and women.

Lys418Asn Polymorphism of the α2-Adrenoceptor Gene Relates to Serum Uric Acid Levels But Not to Insulin Sensitivity

Hyperuricemia is associated with cardiovascular risk. The present study examines the association between serum uric acid (UA) elevation and the α2-, β2-, and β3-adrenoceptor polymorphisms. In 219 nonobese, normotensive, normouricemic (serum UA <6.5 mg/dL at entry) men, serum UA, plasma norepinephrine (NE), the homeostasis model assessment of insulin resistance (HOMA-IR), body mass index, total body fat mass, the α2A(Lys418Asn)-, β2(Arg16Gly, Gln27Glu)-, and β3(Trp64Arg)-adrenoceptor polymorphisms were measured annually over 5 years. Hyperuricemia was defined as a serum UA level of ≥mean+1 SD of 5.0 mg/dL in the participants. At entry, there were 36 subjects who had hyperuricemia and 183 who had normal UA levels. A significant UA elevation for 5 years was defined as an increase in ≥10% in UA levels. There were 82 subjects who had significant UA elevations. The subjects who had hyperuricemia at entry in addition to the subjects who had significant UA elevations over the 5-year period carried a significantly higher frequency of the Asn418 allele of Lys418Asn. Additionally, subjects carrying the Asn418 allele had higher UA and plasma NE and greater elevations in UA over the study period, but HOMA-IR was similar. Insulin resistance at entry and during the study was associated with Arg16Gly polymorphisms but not with Lys418Asn polymorphisms. In conclusion, the Asn418 allele of Lys418Asn is associated with either established hyperuricemia or the progressive elevation of UA over time. This polymorphism was not associated with insulin resistance in nonobese, normotensive individuals. Although hyperuricemia is of known relevance to insulin resistance, it appears to have different genetic determinants from insulin resistance in terms of adrenoceptor polymorphisms.

Benign positional vertigo and hyperuricaemia

OBJECTIVE

To find out if there is any association between serum uric acid level and positional vertigo.

DESIGN

A prospective, case controlled study.

SETTING

A private neurological clinic.

SUBJECTS

All patients presenting with vertigo.

RESULTS

Ninety patients were seen in this period with 78 males and 19 females. Mean age was 47 +/- 3 years (at 95% confidence level) with a standard deviation of 12.4. Their mean uric acid level was 442 +/- 16 (at 95% confidence level) with a standard deviation of 79.6 umol/l as compared to 291 +/- 17 (at 95% confidence level) with a standard deviation of 79.7 umol/l in the control group. The P-value was less than 0.001.

CONCLUSION

That there is a significant association between high uric acid and benign positional vertigo.

A Novel Pattern of Mutation in Uromodulin Disorders: Autosomal Dominant Medullary Cystic Kidney Disease Type 2, Familial Juvenile Hyperuricemic Nephropathy, and Autosomal Dominant Glomerulocystic Kidney Disease

BACKGROUND

Autosomal dominant medullary cystic kidney disease type 2 (MCKD2), familial juvenile hyperuricemic nephropathy (FJHN), and autosomal dominant glomerulocystic kidney disease (GCKD) constitute a hereditary renal disease group that may lead to end-stage renal failure caused by mutations of the UMOD gene and its product, uromodulin or Tamm-Horsfall protein. Of 34 different UMOD mutations described to date, 28 were located in exon 4. Based on such mutation clustering, some investigators have proposed that the sequencing of UMOD exon 4 might become a preliminary diagnostic test for patients with this phenotype.

METHODS

We performed linkage analysis and sequencing of the entire codifying region of the UMOD gene in 4 Spanish families with MCKD/FJHN/GCKD.

RESULTS

All families were shown to present mutations in the UMOD gene. In 3 families, the detected mutations were located in exon 5. Although 1 novel mutation (Gln316Pro) was observed in 2 of these families, a previously reported mutation (Cys300Gly) was found in the other kindred. The Cys300Gly mutation was found in the family presenting with a GCKD phenotype.

CONCLUSION

Our data show a novel mutation pattern in UMOD , suggesting that exon 5 mutations can be more frequent in some populations. Our results support that every exon of the UMOD gene must be included in molecular testing and provide additional evidence for the existence of a fourth calcium-binding epidermal growth factor-like domain in the structure of Tamm-Horsfall protein. A second family reported to date is described, confirming that the GCKD phenotype may be caused by a UMOD mutation.

Gouty arthritis. A primer on late-onset gout

Gouty arthritis, a common source of pain and disability, is the most common form of inflammatory arthritis affecting older people. The authors review the epidemiology and pathogenesis of hyperuricemia and gout, as well as the clinical forms of gouty arthritis. Gout is part of a clinical spectrum of conditions (obesity, diabetes mellitus, hyperlipidemia, coronary artery disease) and need for better patient education on management of these associated conditions is emphasized. The general algorithm of gout management is presented. Clinical particularities of gout presentation in older patients (increased incidence in women, polyarticular onset with hand involvement, earlier development of tophi, association with use of diuretics) are reviewed. Barriers against an optimal control of gout include lack of patient education, presence of comorbid conditions, particularly renal impairment, use of multiple drugs such as diuretics, and cognitive decline. Gout management in older adults remains unsatisfactory.

[Study on hyperuricemia with hyperlipaemia, high blood sugar and hypertension in 1320 elderly people]

OBJECTIVE

To investigate the prevalence of hyperuricemia with hyperlipaemia, high blood sugar and hypertension among elderly people.

METHODS

Serum uric acid (SUA), cholesterol, triglycerides, blood sugar and blood pressure were detected in 1320 elderly people and 6107 people at young and middle age.

RESULTS

The mean SUAs in elderly male and female groups were significantly higher than that in young and middle aged male groups respectively (P < 0.05). The prevalence rates of hyperuricemia in elderly male and female groups were significantly higher than in young and middle aged male groups respectively (P < 0.05). The prevalence rates of hyperlipaemia, high blood sugar and hypertension in the elderly people of hyperuricemia were significantly higher than that in the elderly people of normal serum uric acid (P < 0.05). The prevalence rates of hyperuricemia in the elderly people were complicated by hyperlipaemia, high blood sugar and hypertension which was significantly higher than that in young and middle aged people of hyperuricemia (P < 0.05).

CONCLUSION

Hyperuricemia is a common disease in elderly people and more attention should be paid to the closer relations among hyperuricemia with hyperlipaemia, high blood sugar and hypertension among the elderly.

Renal involvement in Down syndrome

Kidney disease has not been considered a frequent complication in Down syndrome (DS) patients; a variety of urological abnormalities and glomerulopathies have been reported in this population, and some DS patients develop chronic renal failure (CRF). The aim of this study was to improve the understanding of renal disease in patients with DS, focusing on the incidence and range of kidney and urological abnormalities in a population of DS patients. A cross-sectional study was carried out in DS patients referred from a pediatric genetics unit of a tertiary care center. Medical records were reviewed. A 24-h urine specimen and a blood sample were obtained. Fractional excretion of sodium and potassium, tubular reabsorption of phosphate, urinary excretion of calcium, magnesium, uric acid, creatinine clearance and proteinuria were determined. Ultrasound was performed to evaluate the kidneys and the urinary tract. Laboratory data were reviewed for any possible renal disorder. Sixty-nine patients, aged 12 months to 24 years, were recruited. Pathological findings included three cases of voiding disturbances and a case of hypertension in a 7-year old girl. Eight patients (11.6%) had hyperuricemia without gout. Eighteen patients (24.2%) had hyperuricosuria. Urinalysis revealed three cases of mild proteinuria and two patients with microscopic hematuria. Minor radiological abnormalities were found in five patients (7.3%). Three patients (4.5%) had CRF. Renal disease in patients with DS is not as rare as previously thought, although the majority of findings are of minor relevance. According to the variety of pathologies, and in order to detect early irreversible renal injury, it seems quite reasonable to perform regular monitoring of renal function in these patients.

The effect of alcoholic beverage type on hyperuricemia in Japanese male office workers

BACKGROUND: The association between alcohol consumption and risk of hyperuricemia has been pointed out. However, the potential difference in the risk of hyperuricemia according to types of alcoholic beverage has not been assessed.

METHODS: A cross-sectional survey was performed using data from 715 men who had regular medical examinations in their workplace in 2001. Subjects were interviewed using a questionnaire about their lifestyle including types of alcoholic beverages and quantity of alcohol consumed per day. Logistic regression analysis was performed to assess the relationship between the types of alcoholic beverage and high serum uric acid level.

RESULTS: Compared with subjects who did not drink alcohol, the odds ratio (OR) of hyperuricemia (serum uric acid =7.0+ mg/dL) was 2.89 (95% confidence interval [CI]: 1.46-5.71) for subjects who consumed 50+ g/day of ethanol, and 2.64 (95% CI: 1.33-5.24) for subjects who consumed 25-49g/day. Compared with subjects who drank Japanese sake, subjects who drank beer (OR=1.24, 95% CI: 0.55-2.80) or shochu (OR=1.06, 95% CI: 0.44-2.51) did not have a statistically significant difference in risk for hyperuricemia.

CONCLUSION: These findings from a cross-sectional study of Japanese male office workers suggested that alcohol consumption is associated with an increased risk of hyperuricemia and that this increased risk does not vary according to the types of alcoholic beverage.

A community-based epidemiological study of elevated serum alanine aminotransferase levels in Kinmen, Taiwan

AIM: To explore any gender-related differences in prevalence of and condition-associated factors related to an elevated serum alanine aminotransferase (ALT) level amongst residents of Kinmen, Taiwan.

METHODS: A total of 11 898 of a potential 20 112 regional residents aged 30 years or more completed a related questionnaire that was carried out by the Yang-Ming Crusade between 1991 and 1994 inclusively, with blood samples being collected by public nurses. The overall questionnaire response rate was 59.3% (52.4% for males and 66.0% for females).

RESULTS: The prevalence of an elevated serum ALT level for this sub-population was found to be 7.2%, the prevalence revealing a statistically significant decrease with increasing population age (P<0.0001). Males exhibited a greater prevalence of elevated serum ALT level than did females (9.4% vs 5.3%, P<0.0001). Using multiple logistic regression analysis, in addition to male gender, a younger age, greater waist circumference, presence of type-2 diabetes and hyperuricemia were the significant factors associated with an elevated serum ALT level for both males and females. Gender-related differences as regards associated factors were also revealed. For males, obesity was significantly related to an elevated serum ALT level (OR = 1.28, 95%CI: 1.00-1.66) but this was not so for females (OR = 1.09, 95%CI: 0.84-1.42). Hypertriglyceridemia (OR = 1.80, 95%CI: 1.36-2.39) and hyperuricemia (OR = 1.61, 95%CI: 1.03-2.52) were significantly related to elevated serum ALT levels only for females.

CONCLUSION: Several gender-related differences were noted pertaining to the prevalence of and relationship between obesity, hypertriglyceridemia and hyperuricemia and elevated serum ALT level in the present study.

Uric acid and the state of the intrarenal renin-angiotensin system in humans

BACKGROUND

Experimental hyperuricemia is marked by an activated intrarenal renin-angiotensin system (RAS). The renal vascular response to exogenous angiotensin II (Ang II) provides an indirect measure of intrarenal RAS activity. We tested the hypothesis that the serum uric acid concentration predicts the renal vascular response to Ang II.

METHODS

A total of 249 subjects in high sodium balance had the renal plasma flow (RPF) response to Ang II measured. Para-aminohippuric acid (PAH) clearance was used to estimate RPF. Multivariable regression analysis determined if the serum uric acid concentration independently predicts the RPF response to Ang II. Variables considered included age, gender, race, body mass index (BMI), hypertension status, blood pressure, basal RPF, creatinine clearance, serum insulin, serum glucose, serum high-density lipoprotein (HDL), serum triglycerides, and plasma renin activity (PRA).

RESULTS

Uric acid concentration negatively correlated with the RPF response to Ang II (r=-0.37, P < 0.001). In univariate analysis, age, BMI, hypertension, triglycerides, and blood pressure were negatively associated, and basal RPF, HDL, and female gender were positively associated with the RPF response to Ang II. In multivariable analysis, serum uric acid concentration independently predicted the RPF response to Ang II (beta=-5.3, P < 0.001).

CONCLUSION

Serum uric acid independently predicted blunted renal vascular responsiveness to Ang II, consistent with results from experimental hyperuricemia showing an activated intrarenal RAS. This could be due to a direct effect of uric acid or reflect a more fundamental renal process. These data may have relevance to the association of uric acid with risk for hypertension and nephropathy.

Prevention and treatment of the metabolic syndrome

The prevalence of the metabolic syndrome is increasing owing to lifestyle changes leading to obesity. This syndrome is a complex association of several interrelated abnormalities that increase the risk for cardiovascular disease and progression to diabetes mellitus (DM). Insulin resistance is the key factor for the clustering of risk factors characterizing the metabolic syndrome. The National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III defined the criteria for the diagnosis of the metabolic syndrome and established the basic principles for its management. According to these guidelines, treatment involves the improvement of the underlying insulin resistance through lifestyle modification (eg, weight reduction and increased physical activity) and possibly by drugs. The coexistent risk factors (mainly dyslipidemia and hypertension) should also be addressed. Since the main goal of lipid-lowering treatment is to achieve the NCEP low-density lipoprotein cholesterol (LDL-C) target, statins are a good option. However, fibrates (as monotherapy or in combination with statins) are useful for the treatment of the metabolic syndrome that is commonly associated with hypertriglyceridemia and decreased high-density lipoprotein cholesterol (HDL-C) levels. The blood pressure target is < 140/90 mm Hg. The effect on carbohydrate homeostasis should possibly be taken into account in selecting an antihypertensive drug. Patients with the metabolic syndrome commonly have other less well-defined metabolic abnormalities (eg, hyperuricemia and raised C-reactive protein levels) that may also be associated with an increased cardiovascular risk. It seems appropriate to manage these abnormalities. Drugs that beneficially affect carbohydrate metabolism and delay or even prevent the onset of DM (eg, thiazolidinediones or acarbose) could be useful in patients with the metabolic syndrome. Furthermore, among the more speculative benefits of treatment are improved liver function in nonalcoholic fatty liver disease and a reduction in the risk of acute gout.

[Hyperuricaemia in males with obstructive sleep apnoea (osa)]

Previous studies showed that uric acid (UA) excretion in urine is increased in OSA patients and normalized after CPAP therapy. The aim of our study was to assess serum UA in a large group of males with OSA before treatment.

METHODS

All subjects had full or limited PSG, measurements of serum uric acid, cholesterol, triglicerydes, glucose levels, lung function tests and medical history for cardiovascular diseases.

RESULTS

We studied 260 consecutive, obese males (BMI = 33.1 +/- 6.2 kg/m2), mean age 51.5 +/- 9.9 years, with severe OSA (mean AHI/RDI = 44 +/- 24, mean overnight SaO2 = 89.2 +/- 5.4%, T90 = 43.8 +/- 34.4%. Hyperuricaemia (UA >7 mg%) was found in 56.2% of studied subjects. UA concentration correlated with obesity and overnight oxygenation. Multiple regression analysis revealed significant correlation between UA and BMI. Subjects with hyperuricaemia presented with higher prevalence of systemic hypertension, coronary artery disease, diabetes mellitus and COPD.

CONCLUSIONS

Hyperuricaemia is frequent in males with OSA. Elevated UA levels are related to extreme obesity, overnight desaturation and higher prevalence of systemic hypertension, coronary artery disease, diabetes and COPD.

Relations of Serum Uric Acid to Longitudinal Blood Pressure Tracking and Hypertension Incidence

Serum uric acid (UA) has been implicated in the pathogenesis of hypertension. We investigated the relationship of serum UA to hypertension incidence and blood pressure (BP) progression in 3329 Framingham Study participants (mean age 48.7 years; 55.6% women) free of hypertension, myocardial infarction, heart failure, renal failure, or gout. At follow-up 4 years from baseline, 458 persons (13.8%) had developed hypertension, and 1201 persons (36.1%) had experienced progression to a higher BP stage. Age- and sex-adjusted rates of hypertension incidence increased progressively from 9.8% for the lowest quartile to 15.6% for the top quartile of serum UA; BP progression rates increased from 32.8% (lowest quartile) to 39.6% (top quartile). In multivariable analyses adjusting for age, sex, body mass index, diabetes, smoking, alcohol intake, serum creatinine, proteinuria, glomerular filtration rate, baseline BP, and interim weight change, a 1 SD higher serum UA was associated with an odds ratio (OR) of 1.17 (95% confidence interval [CI], 1.02 to 1.33) for developing hypertension, and an OR of 1.11 (95% CI, 1.01 to 1.23) for BP progression. In analyses of a subsample of 3157 individuals not on antihypertensive treatment at the follow-up examination, serum UA was positively associated with changes in systolic ( P =0.02) and diastolic pressure 4 years later ( P =0.04). In summary, serum UA level was an independent predictor of hypertension incidence and longitudinal BP progression at short-term follow-up in our community-based sample.

The serum uric acid and related cardiovascular risk factors in south Taiwan

Hyperuricemia has been shown to be related to cardiovascular morbidity and mortality. Uric acid is a metabolic product synthesized from nucleic acids, amino acids and the Krebs cycle, reflecting a multiple metabolic associations in humans. The relation between uric acid and various cardiovascular metabolic parameters in Asians has rarely been reported on. In this study, we report the relationship between uric acid and various cardiovascular risk factors in 1,027 healthy Taiwanese adults living in Alien, an agricultural town in subtropical South Taiwan. Serum uric acid levels increased in proportion to age in women, but not in men. There were age and gender-specific correlations between uric acid and various cardiovascular metabolic parameters. Triglycerides and creatinine levels were two independent factors predicting serum uric acid levels in men, while only creatinine predicted uric acid levels in women of all age groups. Processes that influence the metabolism of uric acid and its association with other metabolic parameters differs by gender and age.

[The features of uric acid metabolism in women in climacterium]

The purpose of the study was to establish the prevalence of uric acid (UA) metabolism disturbances as a possible risk factor of urate nephropathy in women of various age groups. The authors carried out a retrospective analysis of 757 case histories and performed uricemia and uricosuria screening in women aged 18 to 69 years. The study revealed significant age-dependent elevation of uricemia, with hyperuricemia (HUE) at the age of 60 to 69 years old. The study also found age-dependent increase of HUE rate with its significant elevation in postmenopausal women (older than 50 years), compared with HUE rate in reproductive age women (18 to 49 years old) -37.9% vs. 11.4%. For the first time the researchers established UA excretion level and found a significant tendency of uricosuria to decrease with age (p < 0.016 between the groups of 40 to 49 and 50 to 59 years old). The highest rate of hyperuricosuria was revealed in women of 40 to 49 years old (22.2%), while in women of 18 to 29 and 60 to 69 years old it was 10.1% to 12.1%. For the first time the authors established the rate of hypouricosuria in women, which culminated in women older than 50 (22% of cases). The increase of HUE rate, which is most prominent in postmenopausal women, is associated with the decrease in UA excretion, accompanied by the decrease of hyperuricosuria rate and increase of hypouricosuria rate. Taking into account high prevalence of UA metabolism disturbances in women older than 50, menopause may be considered a risk factor of HUE and urate nephropathy.

High prevalence of hyperuricemia in elderly Taiwanese

Serum urate status, the prevalence of hyperuricemia and their relationship to the metabolic syndrome in elderly Taiwanese were described using data from the Elderly Nutrition and Health Survey in Taiwan (1999-2000), in which a stratified multi-stage clustered sampling scheme was applied. Complete data from biochemical assays and anthropometric measures for 1225 males and 1167 females were included in the analysis. The mean urate level and 95% confidence interval was 411 (398, 424) microM for males and 357 (347, 367) microM for females. Males had significantly higher serum urate levels than females across all age groups (P<0.05). No significant difference in mean serum urate was found among the four age groups of males. On the other hand, females of 75-79 years had significantly higher serum urate levels (376 microM) than that of the 65-69 and>or=80 age groups. The overall prevalence of hyperuricemia (>or=416.7 microM (7.0 mg/dL) in the elderly was 36% (46% for males and 26% for females). Among the participants, 4.2% of males and 1.1% of females were taking medication to lower uric acid. The elderly (males 455 microM; females 416 microM) of the Mountain areas, mainly indigenes, had the highest mean serum urate overall, however, the highest prevalence of hyperuricemia in males was found in the PengHu islands (62%) and that for females in the Mountain areas (51%). The odds ratio (OR) for hyperuricemia was 2.84 for males in the PengHu islands and 4.33 for females in Mountain areas, compared with their counterparts in the third stratum in the northern areas. Adjusting for obesity, alcohol and other related covariates did not alter the relative rank of the ORs in the various strata. Elderly males (22%) had a significantly lower rate of metabolic syndrome (MS) than females (39%) (P<0.05). For both genders, those with MS had a significantly higher mean serum urate (males 436 microM vs. 405 microM; females 389 microM vs. 338 microM) and prevalence of hyperuricemia (males 56% vs. 43%; females 38% vs.19%) (P<0.05). The population attributable risk for MS from hyperuricemia was 18.8% in men and 15.5% in women. In conclusion, the mean serum urate and prevalence of hyperuricemia in the elderly in Taiwan were higher than those found in other populations and was significantly associated with MS. Gene-environmental interaction may play a key role since great geographical variation exists within various Han Chinese groups in Taiwan and between Han Chinese and Taiwanese indigenes.

Association of lower urinary tract symptoms with erectile dysfunction in Japanese men

OBJECTIVES

To assess the age-stratified prevalence of erectile dysfunction (ED) and how lower urinary tract symptoms (LUTS) are associated with ED, and to estimate the correlates of ED among Japanese men.

METHODS

A self-administered questionnaire of the International Prostate Symptom Score and the abridged 5-item version of the International Index of Erectile Function were given to 3189 noninstitutionalized men during a multiphasic health screening. The data from 2084 men who provided complete responses to the questionnaire were analyzed.

RESULTS

The prevalence of moderate to severe ED increased from 13.4% among those younger than 40 years to 20.6%, 39.9%, and 63.1% among those aged 40 to 49, 50 to 59, and 60 years or older, respectively. Most were dissatisfied with their sex life regardless of age. The severity of ED was significantly associated with moderate to severe International Prostate Symptom Scores (age-adjusted odds ratio 1.52), specifically in the urgency (1.75) and nocturia (1.36) domains, and for those with diabetes mellitus (2.54) and coronary artery disease (8.04).

CONCLUSIONS

ED is highly prevalent among Japanese men with LUTS and is significantly associated with the severity of LUTS after controlling for age. This significant aspect of life for men of all ages should be taken into account when treating patients with LUTS.

Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery

BACKGROUND

Weight loss is associated with short-term amelioration and prevention of metabolic and cardiovascular risk, but whether these benefits persist over time is unknown.

METHODS

The prospective, controlled Swedish Obese Subjects Study involved obese subjects who underwent gastric surgery and contemporaneously matched, conventionally treated obese control subjects. We now report follow-up data for subjects (mean age, 48 years; mean body-mass index, 41) who had been enrolled for at least 2 years (4047 subjects) or 10 years (1703 subjects) before the analysis (January 1, 2004). The follow-up rate for laboratory examinations was 86.6 percent at 2 years and 74.5 percent at 10 years.

RESULTS

After two years, the weight had increased by 0.1 percent in the control group and had decreased by 23.4 percent in the surgery group (P<0.001). After 10 years, the weight had increased by 1.6 percent and decreased by 16.1 percent, respectively (P<0.001). Energy intake was lower and the proportion of physically active subjects higher in the surgery group than in the control group throughout the observation period. Two- and 10-year rates of recovery from diabetes, hypertriglyceridemia, low levels of high-density lipoprotein cholesterol, hypertension, and hyperuricemia were more favorable in the surgery group than in the control group, whereas recovery from hypercholesterolemia did not differ between the groups. The surgery group had lower 2- and 10-year incidence rates of diabetes, hypertriglyceridemia, and hyperuricemia than the control group; differences between the groups in the incidence of hypercholesterolemia and hypertension were undetectable.

CONCLUSIONS

As compared with conventional therapy, bariatric surgery appears to be a viable option for the treatment of severe obesity, resulting in long-term weight loss, improved lifestyle, and, except for hypercholesterolemia, amelioration in risk factors that were elevated at baseline.

Childhood uric acid predicts adult blood pressure: the Bogalusa Heart Study

Uric acid has been proposed as an important risk factor in the development of primary hypertension in humans. However, limited information is available linking childhood uric acid levels and blood pressure levels in adulthood. This study examined 334 whites and 243 blacks enrolled in the Bogalusa Heart Study as children aged 5 to 17 years and as adults aged 18 to 35 years. The average follow-up period was 12 years. Childhood uric acid was significantly correlated with childhood and adult blood pressure, both systolic and diastolic. In a multivariate regression analysis, adjusting for age, sex, race, childhood body mass index, childhood uric acid levels, and change in levels of uric acid were significant predictors of adult diastolic blood pressure, whereas change in uric acid was a significant predictor of adult systolic blood pressures. In conclusion, elevated childhood serum uric acid levels are associated with increased blood pressure beginning in childhood and higher blood pressure levels that persist into adulthood, in males and females, whites and blacks, suggesting that early elevations in serum uric acid levels may play a key role in the development of human hypertension.

A high prevalence of renal hypouricemia caused by inactive SLC22A12 in Japanese

BACKGROUND

Recently, SLC22A12 has been identified as a urate-anion exchanger in the human kidney.

METHODS

We screened for polymorphisms of SLC22A12 and conducted an association study between genetic polymorphisms and urate levels in an epidemiologic cohort representing the general population in Japan. Functional significance of mutations was assessed by oocyte expression analysis.

RESULTS

We found five missense, one nonsense, and one deletion mutations [R90H, A226V, R228E, W258Stop, Q312L, D313A (deletion of 313D-333P), and R477H] in 24 subjects with hypouricemia recruited from an epidemiologic cohort (Suita Study) representing the general population in Japan (N= 1875). A statistical analysis indicated that the 90H (N= 14), 477H (N= 5), and 258Stop (hetero + homo N= 82 + 3) alleles were associated with hypouricemia. The alleles 228E and 313A (deletion of 313D-333P) were found just once in the total population. In vitro oocyte expression analysis indicated that 313A (deletion of 313D-333P) had no urate transport activity, indicating that this is a newly identified mutation for idiopathic renal hypouricemia. Intriguingly, the allele frequency of 258Stop was unexpectedly high (2.37%). However, this inactivating mutation does not seem to be harmful in the general population. The effects of common polymorphisms of SLC22A12 were also investigated. Based on linkage disequilibrium, 16 common polymorphisms were categorized into six distinct groups, and six representative genotypes were determined. None of these six common polymorphisms affected the serum uric acid level. A haplotype analysis also suggested that these common genotypes/haplotypes were not important in determining the serum uric acid levels in the general population.

CONCLUSION

SLC22A12 is a major gene for hypouricemia but not hyperuricemia in Japanese.

Which anthropometric indices best predict metabolic disorders in Taiwan?

OBJECTIVES

The aim of this survey was to assess the association between the three simple anthropometric indices (body mass index [BMI], waist-to-hip ratio (WHR), and waist circumference [WC]) and various metabolic disorders, and to identify which indices can best predict metabolic disorders in Taiwan.

METHODS

A cross-sectional hospital-based survey was carried out from January to December 2000. We retrospectively analyzed the medical records of all the patients receiving periodic health examination with scheduled items at China Medical University Hospital. Anthropometric indices, metabolic profiles, and abdominal sonography were performed. A total of 746 people aged 19 to 87 were recruited as subjects for this study. The t test, chi2 test, and stepwise multivariate logistic regression were used.

RESULTS

The subjects included 44.5% women and 55.5% men, with a mean age of 50.74 +/- 12.68 years. After controlling for the other covariables, stepwise multivariate logistic regression showed considerable statistical significance between overall obesity and hypertension, hypertriglyceridemia, hyperuricemia, and fatty liver. There is also statistical significance between abdominal obesity and abnormal ratio of total cholesterol HDL (high-density lipoprotein), hyperuricemia, and fatty liver. None of the indices revealed any association with hyperglycemia, hypercholesterolemia, abnormal low-density lipoprotein, or abnormal HDL.

CONCLUSIONS

BMI and WC can best predict some metabolic disorders. For practical reasons, the combined measurement of BMI and WC is the simple and inexpensive anthropometric index for primary health care settings in the routine physical examinations of adults. We hope this study can establish the background data for further investigation on the epidemiology of anthropometric indices in Taiwan.

[A community-based case-control study on risk factors of hyperuricemia among residents in the community]

OBJECTIVE

To investigate the risk factors of hyperuricemia among residents aged >/= 20 years.

METHODS

A community based case-control study was conducted in 286 patients with 858 controls without hyperuricemia. Available data were analyzed by mono-factorial and multi-factorial logistic regression methods using SPSS 10.0 software.

RESULTS

17 factors related to exposure were identified for hyperuricemia the mono-factorial analysis when; five factors were selected through multiple factoral logistic regression model at P = 0.05 level. The risk factors on hyperuricemia were: hypertriglyceridemia (OR = 3.069), alcohol consumption (OR = 2.032), obesity (OR = 1.802), taste of spicy food (OR = 1.877) and hyperglycemia (OR = 1.622).

CONCLUSION

Hyperuricemia is a disease associated with environment and style-life. Changing lifestyle, such as decreasing alcohol consumption and adopting proper structure of diet may prevent or decrease the chance of getting hyperuricemia and gout.

Increasing prevalence of gout and hyperuricemia over 10 years among older adults in a managed care population

OBJECTIVE

To determine whether the prevalence of gout and/or clinically significant hyperuricemia increased in a managed care population over 10 years.

METHODS

The study was a descriptive analysis utilizing an administrative claims database to ascertain 10-year trends in prevalence of gout and/or hyperuricemia. Prevalence rates were calculated cross-sectionally for each year (1990-99) and expressed/compared as rates per 1000 enrollees.

RESULTS

The prevalence of gout and/or hyperuricemia in the overall population increased by about 2 cases per 1000 enrollees over 10 years. In the > 75 year age group, rates increased from 21 per 1000 persons in 1990 to 41 per 1000 in 1999. In the 65-74 year age group, prevalence increased from between 21 and 24 per 1000 persons in the years 1990-92 to over 31 per 1000 during the years 1997-99. Prevalence rates in younger age groups (< 65 years) stayed consistently low during the years under study. There were sex differences in most age groups, with men having the greater burden of disease at every time point.

CONCLUSION

Prevalence of gout and/or hyperuricemia in the overall study population increased during the 10-year period. When stratified by age, there were increases in prevalence among groups over age 65 in both sexes. Although gout prevalence increased in both sexes over the 10-year period, men still had most of the burden of disease. In ages younger than 65, men had 4 times higher prevalence than women (4:1 ratio), but in the older age groups (> 65), the gender gap narrowed to 1 woman to every 3 men with gout and/or hyperuricemia (3:1 ratio).

Hyperuricemia and cardiovascular risk factor clustering in a screened cohort in Okinawa, Japan

The relation between serum uric acid level and cardiovascular risk factors is complex and has been investigated mainly in men. We examined the correlation between serum uric acid level and obesity, hypertension, dyslipidemia, and diabetes mellitus (DM) in both men and women of a screened cohort in Okinawa, Japan. A total of 9,914 individuals (6,163 men and 3,751 women ranging in age from 18 to 89 years) who were screened at Okinawa General Health Maintenance Association were subjects in this study. Hyperuricemia was defined as a serum uric acid level > or = 7.0 mg/dl in men and > or = 6.0 mg/dl in women. The odds ratios (95% confidence intervals) for the presence of hyperuricemia in men were 1.75 (1.56-1.97) for obesity, 1.42 (1.25-1.62) for hypertension, 1.16 (1.02-1.30) for hypercholesterolemia, 1.80 (1.60-2.03) for hypertriglyceridemia, 1.19 (1.02-1.40) for hypo-high density lipoprotein (HDL) cholesterolemia, and 0.61 (0.49-0.75) for DM; in women, they were 2.02 (1.62-2.53) for obesity, 1.64 (1.29-2.10) for hypertension, 1.31 (1.04-1.65) for hypercholesterolemia, 1.95 (1.51-2.51) for hypertriglyceridemia, 1.53 (0.96-2.44) for hypo-HDL cholesterolemia, and 1.20 (0.76-1.90) for DM. Hyperuricemic subjects had higher rates of coexistence of two or more of these cardiovascular risk factors than non-hyperuricemic subjects (63.8% vs. 43.2% in men; 58.9% vs. 27.6% in women). The present study revealed that hyperuricemia is positively associated with obesity, hypertension, and dyslipidemia in both men and women, and that hyperuricemic subjects tend to have a clustering of these cardiovascular risk factors.

Different progressions of hyperglycemia and diabetes among hyperuricemic men and women in the kinmen study

OBJECTIVE

A 7-year followup study among hyperuricemic subjects was conducted to investigate the association between longterm hyperuricemia and subsequent hyperglycemia and diabetes mellitus. The possible sex difference was also investigated.

METHODS

A total of 641 hyperuricemic subjects aged 30 years and over (391 men, 250 women) screened from the community-based Kinmen Study in 1991-92 (the baseline study) were followed in 1997-98, with 75% followup rate. Demographic, clinical, and biochemical data were collected in both baseline and followup periods.

RESULTS

After followup for 7 years, the distribution of plasma glucose concentrations changed moderately among male hyperuricemic subjects, but increased markedly among female subjects. The increase of uric acid levels during the followup period was correlated with subsequent diabetes only among hyperuricemic women. Moreover, a relatively higher incidence of diabetes was found in postmenopausal hyperuricemic women after 7-year followup.

CONCLUSION

Although the direct role and causality played by uric acid cannot be confirmed by this study, the findings, as applicable to a Chinese nondiabetic population, show that specific progressions of plasma glucose concentrations were significantly different between male and female hyperuricemic subjects. Hyperuricemia and persistent increase in uric acid levels among postmenopausal women should alert physicians to the possibility of subsequent hyperglycemia and diabetes.

Hypertension was the major risk factor leading to development of cardiovascular diseases among men with hyperuricemia

OBJECTIVE

A 7-year followup study among men with hyperuricemia was conducted to study the longterm relationships between serum uric acid concentrations and cardiovascular diseases. Any interaction between uric acid levels and other risk factors (e.g., obesity, hypertension) on the development of cardiovascular diseases was also examined.

METHODS

A total of 391 men with hyperuricemia aged 30 and over screened from the community-based Kinmen study in 1991-92 (the baseline study) were followed in 1997-98, with a 75% followup rate. Demographic, clinical, and biochemical data were collected in both baseline and followup periods.

RESULTS

After followup for 7 years, the significant risk factors of coronary heart disease were age, increase of uric acid level at followup, baseline systolic blood pressure, and increase of systolic blood pressure at followup. Factors independently associated with left ventricular hypertrophy included baseline systolic blood pressure and increase of systolic blood pressure at followup. Gouty syndrome, age, baseline fasting plasma glucose level, and increase of systolic blood pressure followup were significantly related to cardiac arrhythmia. After adjusting for baseline serum uric acid level, we found that hyperuricemic men with hypertension, especially overt hypertension stage 2 and stage 3, would predict cardiovascular disease incidence synergistically with uric acid level.

CONCLUSION

There is a positive and statistically significant relationship between gout and subsequent cardiac arrhythmia. Moreover, hypertension was the major risk factor leading to aggravation of development of atherosclerosis among hyperuricemic subjects. Gout and elevated uric acid level seemed not to be an independent risk factor for most cardiovascular diseases. Nevertheless, blood pressure level was predictive for cardiovascular disease incidence synergistically with serum uric acid level.

REDUCED INCIDENCE OF HYPERURICEMIA, GOUT, AND RENAL FAILURE FOLLOWING LIVER TRANSPLANTATION IN COMPARISON TO HEART TRANSPLANTATION: A LONG-TERM FOLLOW-UP STUDY

BACKGROUND

Hyperuricemia and gout are common complications of heart transplantation, reaching a prevalence of 84% and 30%, respectively, in heart transplant recipients. In contrast, they are seldom reported following orthotopic liver transplantation (OLT).

METHODS

We retrospectively evaluated 75 consecutive liver transplant recipients and 47 consecutive heart transplant recipients, followed for at least 3 years after transplantation in a single transplantation center in Jerusalem, Israel. Data was collected on demographic and clinical variables, levels of uric acid, the occurrence of gout, renal function, and variables effecting hyperuricemia, such as weight and medications.

RESULTS

Clinical gout was significantly more prevalent in heart recipients than in liver recipients (25.5% and 2.6%, respectively). Hyperuricemia was present in 100% of heart recipients, with an average uric acid level of 451 micromol/l, as compared with 85.7% and 403 micromol/l for liver recipients (P < 0.001 for both variables). Univariate analysis identified several parameters which significantly influenced the difference in hyperuricemia and gout among the two groups including age, gender, rejection episodes, hypertension, diabetes mellitus, the level of uric acid prior to transplantation, and the use of cyclosporine A, diuretics, steroids, and aspirin. Use of tacrolimus and azathioprine were associated with decreased incidence of hyperuricemia and gout. Multivariate analysis identified the type of transplantation as the only independent risk factor predicting the development of hyperuricemia and gout.

CONCLUSION

Clinical gout and hyperuricemia were significantly more prevalent in heart recipients than in liver recipients. The disparity can be explained by differences in age, gender and renal function among the groups, as well as by the use of different medication regimens.

Recent trends of hyperuricemia and obesity in Japanese male adolescents, 1991 through 2002

The aim of the present study was to determine the change of serum uric acid (UA) levels in male adolescents and to characterize the relationship between UA levels and obesity or its related factors. This study was conducted in 17,155 students at enrollment in Okayama University from 1991 through 2002, in which the mean serum UA level as a whole was 5.64 +/- 0.009 mg/dL (mean +/- SEM) and the incidence of hyperuricemia (>/=7.6 mg/dL) was 4.13%. Serum UA levels were correlated with obesity-related indicators, including body mass index (BMI; r = 0.282, P <.0001) and skin-fold thickness (r = 0.286, P <.0001). The incidence of hyperuricemia was increased in parallel with BMI. In the last 4 years (1999 through 2002) of the study period, serum UA levels (5.76 mg/dL) and the incidence of hyperuricemia (4.5%) were significantly increased compared with those in the earlier period (1991 through 1994: 5.50 mg/dL and 3.5%, respectively). However, BMI has been rather gradually decreased throughout 12-year observation in all the subjects. Hyperuricemia was related to the presence of other risk factors, including hypercholesterolemia, liver function abnormality, and hypertension. The frequencies of such abnormalities were higher than euuricemic subjects and this trend was notable in the most recent students enrolled from 1999 through 2002. Hyperuricemia was even found in the group of non-obese male adolescents. Taking into consideration that hyperuricemia is associated with a high prevalence of lifestyle-related diseases in adults, it is of great importance to prevent hyperuricemia at the early stage in Japanese adolescents.

The C677 mutation in methylene tetrahydrofolate reductase gene: correlation with uric acid and cardiovascular risk factors in elderly Korean men

The C677T mutation in the methylene tetrahydrofolate reductase (MTHFR) gene results in elevated homocysteine levels and, presumably, in increased cardiovascular risk. Moreover, elevated homocysteine levels are reportedly associated with high serum uric acid levels. We evaluated the MTHFR genotype and a panel of biochemical, hematological variables, and lifestyle characteristics in 327 elderly Korean men (age range 40-81 yr; mean, 51.87). This study shows that mutation of the MTHFR gene may be a risk for hyperuricemia. The mean uric acid levels for the C/C, C/T and T/T genotypes were 5.54, 5.91 and 6.33 mg/dL, respectively (p=0.000). The T/T genotype was significantly more frequent in subjects with high uric acid levels (p=0.003). Thus, this mutation of the MTHFR gene is implied by the study results to be a risk factor of hyperuricemia in elderly Korean men. However, the relationship between the MTHFR mutation and uric acid metabolism remains unclear. Therefore, further studies are necessary to explain the associated between the MTHFR mutation and elevated uric acid levels, and to examine potential relationships between it and conventional cardiovascular risk factors.

Prevalence of hyperuricemia and relation of serum uric acid with cardiovascular risk factors in a developing country

Background

The prevalence of hyperuricemia has rarely been investigated in developing countries. The purpose of the present study was to investigate the prevalence of hyperuricemia and the association between uric acid levels and the various cardiovascular risk factors in a developing country with high average blood pressures (the Seychelles, Indian Ocean, population mainly of African origin).

Methods

This cross-sectional health examination survey was based on a population random sample from the Seychelles. It included 1011 subjects aged 25 to 64 years. Blood pressure (BP), body mass index (BMI), waist circumference, waist-to-hip ratio, total and HDL cholesterol, serum triglycerides and serum uric acid were measured. Data were analyzed using scatterplot smoothing techniques and gender-specific linear regression models.

Results

The prevalence of a serum uric acid level >420 μmol/L in men was 35.2% and the prevalence of a serum uric acid level >360 μmol/L was 8.7% in women. Serum uric acid was strongly related to serum triglycerides in men as well as in women (r = 0.73 in men and r = 0.59 in women, p < 0.001). Uric acid levels were also significantly associated but to a lesser degree with age, BMI, blood pressure, alcohol and the use of antihypertensive therapy. In a regression model, triglycerides, age, BMI, antihypertensive therapy and alcohol consumption accounted for about 50% (R2) of the serum uric acid variations in men as well as in women.

Conclusions

This study shows that the prevalence of hyperuricemia can be high in a developing country such as the Seychelles. Besides alcohol consumption and the use of antihypertensive therapy, mainly diuretics, serum uric acid is markedly associated with parameters of the metabolic syndrome, in particular serum triglycerides. Considering the growing incidence of obesity and metabolic syndrome worldwide and the potential link between hyperuricemia and cardiovascular complications, more emphasis should be put on the evolving prevalence of hyperuricemia in developing countries.

Serum uric acid in traditional Pacific Islanders and in Swedes

BACKGROUND

In some western populations, increased serum uric acid has been positively associated with cardiovascular disease, possibly because hyperuricaemia could be an untoward part of the insulin-resistant metabolic syndrome. However, there is evidence that uric acid is a free radical scavenger capable of inhibiting LDL oxidation. Amongst the traditional horticulturalists of Kitava, Trobriand Islands, Papua New Guinea, cardiovascular disease, hypertension, hyperinsulinaemia and abdominal obesity are absent or rare. In contrast, serum triglycerides are similar to Swedish levels.

OBJECTIVE

To compare serum uric acid between nonwesternized and westernized populations.

METHODS

Fasting levels of serum uric acid were measured cross-sectionally in 171 Kitavans aged 20-86 years and in 244 randomly selected Swedish subjects aged 20-80 years.

RESULTS

There were small differences in serum uric acid between the two populations, although a slight increase with age was found only in Swedish males (r = 0.20; P = 0.03) and females (r = 0.36; P < 0.0001). Above 40 years of age, uric acid was approximately 10% lower in Kitavans, a difference which was statistically significant only in males, possibly because of the limited number of females. Regarding hyperuricaemia, two Kitavan males had uric acid above 450 micromol L-1 whilst none of the females was above 340 micromol L-1. Amongst the Swedish subjects, five of 117 males and 19 of 127 females had hyperuricaemia according to these definitions.

CONCLUSION

The rather similar uric acid levels between Kitava and Sweden imply that uric acid is of minor importance to explain the apparent absence of cardiovascular disease in Kitava.

Influence of cyclosporin A (CyA) on renal handling of urate

Hyperuricaemia is a frequent side-effect of cyclosporin A (CyA) therapy in renal transplant patients, and gout arthritis is the cause of considerable morbidity among these patients. However, neither the potential predisposing factors nor the mechanisms of hyperuricaemia have been clearly elucidated. It has been reported that hyperuricaemia in patients on CyA is associated with a lowered glomerular filtration rate, or with a reduced urate clearance, due to an increase in the net tubular urate reabsorption or to a decrease in secretion. These conclusions are mostly supported by measurements of the basal clearance rate and fractional excretion of urate, but more precise studies of renal handling of urate by the renal tubule have seldom been performed. The purpose of our study was to investigate the prevalence of hyperuricaemia in our population of renal transplant patients, as well as the risk factors involved. Furthermore, we have evaluated the mechanism of hyperuricaemia by a combined pyrazinamide and probenecid test allowing a better evaluation of urate transport processes than pyrazinamide alone.

[Treatment of reno-ureteral lithiasis with ESWL in obese patients. Apropos of 150 patients]

OBJECTIVES

Obesity is considered a significant risk factor for diseases such as hypertension, diabetes, coronary artery disease, and metabolic diseases, increasing considerably the risk for surgery. We have treated with ESWL a significant number of patients with the aim of avoiding operations which could be long and have associated complications due to the patient's condition.

METHODS

From April 2000 to May 2002 we treated 150 obese patients with kidney and/or ureteral stones using a Nova Ultima lithotripter. 94% of the patients were treated with a neuroleptoanalgesic drug, and 6% of the cases required narcotic-neuroleptoanalgesia. 85% of the cases were admitted for 24 hours, and 15% were outpatient. 94 males and 56 females who weighted more than 90 kg (91-141 kg) and more than 80 kg (80-127 kg) respectively were treated. Mean age was 41 years (range 20-72). 134 stones were located in the kidney, 27 in the pelvis and 16 in the ureter (25 patients presented bilateral lithiasis and 2 one ureteral stone and one homolateral kidney stone). Mean stone size was 12 mm. Stone track down was easy in 64% of the cases and difficult in 36%, mainly ureteral and pelvic stones. All patients received 3,000 shock waves at 21-22 KV and high energy with an average time per session of 35 minutes. Ultrasound tracking was preferred in 80% of the patients.

RESULTS

Results at three months were: 72% stone-free, 9% < 4 mm, 14% > = 4 mm, and 5% failures. Best results were obtained in pelvic and lumbar ureter stones (88%). Mean retreatment was 1.6, with one additional session in 34 patients, two sessions in 8, and three sessions in 5.

CONCLUSIONS

In the treatment of urolithiasis in obese patients, lithotriptor machine characteristics and operator experience are very important. The knowledge and the application of stone tracking systems allow the urologist to obtain a higher percentage of stone free patients. These techniques are important in these patients because positioning is key to obtain a good result. The indication of ESWL in obese patients is a good choice but selection criteria should be respected. The percentage of stone free patients at three months has been satisfactory and complications are similar to those published by other authors.

Pan-European multicentre economic evaluation of recombinant urate oxidase (rasburicase) in prevention and treatment of hyperuricaemia and tumour lysis syndrome in haematological cancer patients

GOALS

Hyperuricaemia (HU) and tumour lysis syndrome (TLS) are complications of acute myeloid/lymphoid leukaemia (AML/ALL) and non-Hodgkin lymphoma (NHL) leading to increased morbidity and mortality. The objective was to assess incremental cost-effectiveness ratios (ICER) of preventing/treating HU and TLS with recombinant urate oxidase, rasburicase (Fasturtec/Elitek).

PATIENTS AND METHODS

Incidence and costs of HU and TLS were based on a multi-country chart review. Life expectancy at the time of diagnosis was based on published survival rates and age at diagnosis. Reductions of HU/TLS following treatment with rasburicase were based on clinical trial data.

RESULTS

Prevention with rasburicase appears highly cost-effective in children (ICER between Eur 425 and Eur 3054 per life-year saved, LYS). In adults, prevention is more cost-effective in NHL and ALL (maximum ICER of Eur 41383 and Eur 32126 per LYS). Treatment of established HU/TLS with rasburicase is cost-saving in children and highly cost-effective in adults. The results are robust in children. In adults, the prevention strategy appears sensitive to the risk of HU/TLS.

CONCLUSIONS

In conclusion, rasburicase, in addition to the demonstrated clinical benefit, is an economically attractive new option in the treatment of HU, both in adults and children. In prevention the drug has an attractive economic profile in children, and is cost-effective in adults with ALL and NHL.

Incidence, medical resource utilisation and costs of hyperuricemia and tumour lysis syndrome in patients with acute leukaemia and non-Hodgkin's lymphoma in four European countries

Hyperuricemia (HU) and tumour lysis syndrome (TLS) are complications of acute leukaemia and non-Hodgkin lymphoma (NHL) leading to increased morbidity and mortality. The objective of this study was to define incidence and calculate health care cost associated with HU and TLS. 788 acute leukaemia and NHL patients from Belgium, The Netherlands, Spain and UK were screened retrospectively for HU and TLS. Resource use related to HU and TLS was recorded and costs were calculated applying local unit costs. Results showed that HU occurred in 18.9% of patients, and 27.8% of them fulfilled TLS criteria. The cost of HU without TLS was 672 euros (SE 181), the cost of TLS 7,342 euros (SE 1,412). TLS requiring dialysis incurred an average cost of 17,706 euros. In conclusion, it is noted that the observed incidence rates were lower than earlier reports. In addition, some risk factors for HU and TLS (e.g. paediatric patients versus adults) were not associated with increased rates of HU or TLS as a consequence of higher rates of prevention. TLS cases incurred 11 times higher costs than HU cases in which TLS was absent. The main cost drivers in TLS are interventions requiring intensive care.

Hyperuricemia and gout in renal transplant recipients

Hyperuricemia, unlike clinical gout, is extremely common in renal transplant patients. The high prevalence of hyperuricemia is related to prolonged exposure to cyclosporine rather than to its dose or serum concentration. Serum creatinine levels do not show significant correlation with hyperuricemia, behaving more like a surrogate marker for cyclosporine dose and trough level. The low incidence of gout in renal transplant patients, despite the hyperuricemia, may be related to the prolonged immunosuppression effect.