Association between allopurinol and mortality among Japanese hemodialysis patients: results from the DOPPS

Influence of xanthine oxidase inhibitors on all-cause mortality in adults: a systematic review and meta-analysis

Xanthine oxidase inhibitors, including allopurinol and febuxostat, are the first-line treatment of hyperuricemia. This meta-analysis investigated the association between urate-lowering therapy and all-cause mortality in different chronic diseases to match its users and non-users in a real-world setting. Overall, 11 studies were included, which reported adjusted hazard ratios for all-cause mortality over at least 12 months. Meta-analysis of all included studies showed no effect of the therapy on all-cause mortality. However, subgroup analyses showed its beneficial effect in patients with chronic kidney disease (14% risk reduction) and hyperuricemia (14% risk reduction), but not in patients with heart failure (28% risk increase). Urate-lowering therapy reduces all-cause mortality among patients with hyperuricemia and chronic kidney disease, but it seems to increase mortality in patients with heart failure and should be avoided in this subgroup.

Myocardial markers are highly altered by higher rates of fluid removal during hemodialysis

INTRODUCTION

Although hemodialysis is lifesaving in patients with kidney failure extensive interdialytic weight gain (IDWG) between dialyses worsens the prognosis. We recently showed a strong correlation between IDWG and predialytic values of cardiac markers. The aim of the present study was to evaluate if the cardiac markers N-terminal pro-B-type natriuretic peptide (proBNP) and troponin T were influenced by IDWG and speed of fluid removal (ultrafiltration-rate).

METHODS

Twenty hemodialysis patients performed in total 60 hemodialysis (three each). Predialytic values of proBNP and troponin T and changes from predialysis to 180 min hemodialysis (180-0 min) were compared with the IDWG calculated in percent of body weight. The ultrafiltration-rate was adjusted (UF-rateadj ) to IDWG: (100 × weight gain between dialysis [kg])/(estimated body dry weight [kg] × length of hemodialysis session [hours]).

RESULTS

UF-rateadj correlated (Spearman) with (1) predialytic values of IDWG (r = 0.983, p < 0.001), proBNP (r = 0.443, p < 0.001), and troponin T (r = 0.296, p = 0.025); and (2) differences in proBNP180-0min (r = 0.572, p < 0.001) and troponin T180-0min (r = 0.400, p = 0.002). UF-ratesadj above a breakpoint of 0.60 caused more release of proBNP180-0min (p = 0.027). Remaining variables in multiple regression analysis with ProBNP180-0min as dependent factor were predialytic proBNP (p < 0.001) and the ultrafiltration-rate (p < 0.001).

CONCLUSION

Higher UF-rateadj during dialysis was correlated to increased levels of cardiac markers. Data support a UF-rateadj lower than 0.6 to limit such increase. Further studies may confirm if limited fluid intake and a lower UF-rateadj should be recommended to prevent cardiac injury during dialysis.

Serum Urate Levels of Hemodialyzed Renal Patients Revisited

OBJECTIVES

The need of maintaining serum urate (SU)-lowering agents in hemodialysis (HD) patients is an understudied area that requires a review, as it is a common practice. The aims were to assess the SU reduction achieved under HD and to analyze the kinetics of SU in a week of intermittent HD.

METHODS

The serum urate levels were determined before and after HD sessions in 96 consecutive patients with end-stage renal disease, and the average SU reduction was assessed. Variables related to HD were analyzed whether they were associated with SU reductions of 80% greater. In addition, a kinetics study was performed on 10 selected patients with hyperuricemia (SU before HD >6.8 mg/dL) throughout intermittent HD sessions in a 1-week period.

RESULTS

The mean ± SD age of the patients was 66.5 ± 13.8 years, and 62 of them were male (64.6%). The mean ± SD time on HD replacement was 7.1 ± 7.2 years, and 16 (16.4%) continued with urate-lowering agents. The mean SU reduction immediately after HD was 80.2% (95% confidence interval, 78.4-82.0); 51 patients (56.7%) showed SU reduction of 80% or greater. In the SU kinetics study, SU levels significantly reduced all over the period and persisted below hyperuricemia threshold (p = 0.015). Noteworthy, 6 patients (60%) were hyperuricemic before session 1, but only 1 (10%) before session 2 and none before session 3.

CONCLUSIONS

Under HD replacement therapy, the SU levels effectively reduced and persisted below saturation point, suggesting that the SU-lowering therapy would be unnecessary for patients on HD, but necessary in selected cases. The definition of hyperuricemia under HD needs to be revised.

Effectiveness of Allopurinol in Reducing Mortality: Time-Related Biases in Observational Studies

OBJECTIVE

The treatment of gout with allopurinol is effective at reducing urate levels and the frequency of flares. Several observational studies have shown important reductions in mortality with allopurinol use, with wide variations in results. We undertook this review to assess the extent of bias in these studies, particularly time-related biases such as immortal time bias.

METHODS

We searched the literature to identify all observational studies describing the effect of allopurinol use versus nonuse on all-cause mortality.

RESULTS

We identified 12 observational studies, of which 3 were affected by immortal time bias and 3 by immeasurable time bias, while the remaining 6 studies avoided these time-related biases. Reductions in all-cause mortality with allopurinol use were observed among the studies with immortal time bias, with a pooled hazard ratio (HR) of death associated with allopurinol of 0.71 (95% confidence interval [95% CI] 0.50-1.01), as well as in those with immeasurable time bias (pooled HR 0.62 [95% CI 0.56-0.67]). The 6 studies that avoided these biases demonstrated a null effect of allopurinol on mortality (pooled HR 0.99 [95% CI 0.87-1.11]), though the lack of an analysis based on treatment adherence may have attenuated the effect.

CONCLUSION

Observational studies are important to provide real-world data on medication effects. The observational studies showing significantly decreased mortality with allopurinol treatment cannot be used as evidence, however, mainly due to time-related biases that tend to greatly exaggerate the potential benefit of treatments. The ALL-HEART randomized trial, which is currently underway and evaluates the effect of adding allopurinol to usual care (compared to no added treatment), will provide reliable evidence on mortality.

Hyperuricemia in Kidney Disease: A Major Risk Factor for Cardiovascular Events, Vascular Calcification, and Renal Damage

Kidney disease, especially when it is associated with a reduction in estimated glomerular filtration rate, can be associated with an increase in serum urate (uric acid), suggesting that hyperuricemia in subjects with kidney disease may be a strictly secondary phenomenon. Mendelian randomization studies that evaluate genetic scores regulating serum urate also generally have not found evidence that serum urate is a causal risk factor in chronic kidney disease. Nevertheless, this is countered by a large number of epidemiologic, experimental, and clinical studies that have suggested a potentially important role for uric acid in kidney disease and cardiovascular disease. Here, we review the topic in detail. Overall, the studies strongly suggest that hyperuricemia does have an important pathogenic role that likely is driven by intracellular urate levels. An exception may be the role of extracellular uric acid in atherosclerosis and vascular calcification. One of the more striking findings on reviewing the literature is that the primary benefit of lowering serum urate in subjects with CKD is not by slowing the progression of renal disease, but rather by reducing the incidence of cardiovascular events and mortality. We recommend large-scale clinical trials to determine if there is a benefit in lowering serum urate in hyperuricemic subjects in acute and chronic kidney disease and in the reduction of cardiovascular morbidity and mortality in subjects with end-stage chronic kidney disease.

Rationale and design for Lowering-hyperUricaemia treatment on cardiovascular outcoMes In peritoNeal diAlysis patients: a prospective, multicentre, double-blind, randomised controlled trial (LUMINA)

INTRODUCTION

The prevalence of hyperuricaemia in peritoneal dialysis patients is quite high. Studies have demonstrated a correlation between hyperuricaemia and cardiovascular disease and treatment of hyperuricaemia reportedly reduces cardiovascular risk in patients with chronic kidney disease. However, whether hyperuricaemia treatment benefits cardiovascular outcomes in continuous ambulatory peritoneal dialysis (CAPD) patients is not yet known.

METHODS AND ANALYSES

This prospective, multicentre, double-blind, randomised controlled trial was designed to evaluate the effects of hyperuricaemia treatment on cardiovascular event risk in CAPD patients. Based on a power of 80%, with type I error α=0.05, two-sided test and 1:1 parallel control study, considering a dropout rate of 20%, a total of 548 eligible patients are expected to be randomly assigned to either the hyperuricaemia treatment group (febuxostat) or control group (placebo).

ETHICS AND DISSEMINATION

This study has been approved by the Medical Ethics Committee of the First Affiliated Hospital, Sun Yat-sen University and the ethics committees of other participating institutions. Written informed consent will be obtained from potential trial participants or authorised surrogates.The findings of the study will be disseminated through publications in peer-reviewed journals, and presentations at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT03200210. 25 June 2017. The trial was started on 13 July 2017, and is expected to end by 31 December 2022. Till 20 Jan 2020, a total of 548 patients have been recruited.

PROTOCOL VERSION

The protocol version number and date are YLT-1604-V2.0 and 15 December 2016.

Association of gout with major adverse cardiovascular events and all-cause mortality in patients with peripheral artery disease

BACKGROUND AND AIMS

Prior epidemiological studies have suggested that individuals with gout are at greater risk of cardiovascular events, but there have been no studies in people with peripheral artery disease (PAD). The aim of this study was to investigate the relationship between gout and major adverse cardiovascular events (MACE) and all-cause mortality in people with PAD.

METHODS

Participants with a range of PAD presentations, including carotid artery disease, aortic or peripheral aneurysm and lower limb PAD, were prospectively recruited from outpatient vascular departments within Australia. MACE (myocardial infarction, stroke or cardiovascular death) and all-cause mortality were identified through out-patient follow-up and linked medical records. Propensity-score matching was undertaken to generate a matched cohort of patients with and without a history of gout. Kaplan-Meier survival analysis and Cox-proportional hazard analysis were used to examine the association of gout with MACE and all-cause mortality.

RESULTS

A total of 4308 people with PAD, of whom 334 had a history of gout, were included and followed for a median (inter-quartile range) of 2.1 (0.1-5.9) years. In the unadjusted analyses, participants with gout were at increased risk of MACE (hazard ratio, HR 1.37, 95% confidence intervals, CI 1.09-1.71, p = 0.006) and all-cause mortality (HR 1.38, 95% 1.13-1.68, p = 0.002), however, the associations were lost in the adjusted analyses. In the propensity-score matched cohort, gout was not significantly associated with an increased risk for MACE or all-cause mortality.

CONCLUSIONS

Gout was not independently associated with increased cardiovascular events in PAD patients.

Extreme hyperuricemia is a risk factor for infection-related deaths in incident dialysis patients: a multicenter prospective cohort study

Introduction

There are few studies on the association between serum uric acid (UA) level and mortality in incident dialysis patients. We aimed to clarify whether the serum UA level at dialysis initiation is associated with mortality during maintenance dialysis.

Methods

We enrolled 1486 incident dialysis patients who participated in a previous multicenter prospective cohort study in Japan. We classified the patients into the following five groups according to their serum UA levels at dialysis initiation: G1 with a serum UA level <6 mg/dL; G2, 6.0–8.0 mg/dL; G3, 8.0–10.0 mg/dL; G4, 10.0–12.0 mg/dL; and G5, ≥12.0 mg/dL. We created three models (Model 1: adjusted for age and sex, Model 2: adjusted for Model 1 + 12 variables, and Model 3: stepwise regression adjusted for Model 2 + 13 variables) and performed a multivariate Cox proportional hazard regression analysis to examine the association between the serum UA level and outcomes, including infection-related mortality.

Results

Hazard ratios (HRs) were calculated relative to the G2, because the all-cause mortality rate was the lowest in G2. For Models 1 and 2, the all-cause mortality rate was significantly higher in G5 than in G2 (HR: 1.63, 95% confidence interval [CI]: 1.14–2.33 and HR: 1.78, 95% CI: 1.19–2.68, respectively). For Models 1, 2, and 3, the infection-related mortality rate was significantly higher in G5 than in G2 (HR: 2.75, 95% CI: 1.37–5.54, HR: 3.09, 95% CI: 1.45–6.59, HR: 3.37, and 95% CI: 1.24–9.15, respectively).

Conclusions

Extreme hyperuricemia (serum UA level ≥12.0 mg/dL) at dialysis initiation is a risk factor for infection-related deaths.

Dysfunctional ABCG2 gene polymorphisms are associated with serum uric acid levels and all-cause mortality in hemodialysis patients

Dysfunctional variants of ATP-binding cassette transporter subfamily G member 2 (ABCG2), a urate transporter in the kidney and intestine, are the major causes of hyperuricemia and gout. A recent study found that ABCG2 is a major transporter of uremic toxins; however, few studies have investigated the relationship between ABCG2 gene polymorphisms and mortality. This prospective cohort study of 1214 hemodialysis patients investigated the association between serum uric acid levels and ABCG2 genotype and mortality. Genotyping of dysfunctional ABCG2 variants, Q126X (rs72552713) and Q141K (rs2231142), was performed using the patients’ DNA. During the study period, 220 patients died. Lower serum uric acid levels were associated with higher mortality (hazard ratio [HR] 1.89, 95% confidence interval [CI] 1.14–3.10, P ≤ 0.001). ABCG2 dysfunction, estimated by genetic variants, had a significant positive association with serum uric acid levels (full function: 7.4 ± 1.2 mg/dl, 3/4 function: 7.9 ± 1.3 mg/dl, 1/2 function: 8.2 ± 1.4 mg/dl, ≤ 1/4 function: 8.7 ± 1.3 mg/dl, P ≤ 0.001). This association remained significant on multiple regression analysis. The Cox proportional hazard analysis indicated that the ABCG2 ≤ 1/4 function type was significantly associated with higher mortality (HR 6.66, 95% CI 2.49 to 17.8, P ≤ 0.001) than the other function types. These results showed that ABCG2 plays a physiologically important role in uric acid excretion, and that ABCG2 dysfunction is a risk factor for mortality in hemodialysis patients.

Representativeness of Randomized Clinical Trial Cohorts in End-stage Kidney Disease: A Meta-analysis

IMPORTANCE

Systematic differences between patients included in randomized clinical trials (RCTs) and the general patient population may influence the generalizability of RCT findings. Comprehensive national registries of patients with end-stage kidney disease who are undergoing dialysis provide a unique opportunity to compare trial and real-world patient cohorts.

OBJECTIVE

To determine if participants in large, multicenter dialysis trials were similar to the general population undergoing dialysis in terms of age, comorbidities, and mortality rate.

DATA SOURCES

MEDLINE, PubMed, and the Cochrane Central Register of Controlled Trials were systematically searched on January 6, 2017, for studies published from January 1, 2007, to December 31, 2016. Data sources were published manuscripts, supplementary material, and trial registration information. Data on the general population undergoing dialysis were derived from the US Renal Data System (USRDS). Data were analyzed from March 17 to July 22, 2018.

STUDY SELECTION

Randomized clinical trials enrolling only participants undergoing dialysis for end-stage kidney disease with 100 or more adult participants from 2 or more sites.

DATA EXTRACTION AND SYNTHESIS

Abstract screening and data extraction were performed independently by 2 researchers. Data were pooled using a random-effects model.

MAIN OUTCOMES AND MEASURES

The primary outcome was difference in mean age between the RCT and USRDS populations. Secondary outcomes included differences in mortality rate and comorbidities.

RESULTS

The search identified 186 RCTs, enrolling 79 104 participants. Compared with the 2011 USRDS population, RCT participants were younger (mean age, 58.9 years; 95% CI, 58.3-59.5 years vs 61.2 years; P < .001), more likely to be male (58.9%; 95% CI, 57.6%-60.1% vs 55.7%; P < .001), and have coronary artery disease (26.9%; 95% CI, 22.2%-31.7% vs 17.7%; P < .001) and less likely to have diabetes (40.2%; 95% CI, 36.7%-43.6% vs 44.2%; P = .03) or heart failure (19.6%; 95% CI, 15.1%-24.0% vs 29.8%; P < .001). The mortality rate per 100 patient-years during trial participation was less than half that of the USRDS population (8.9; 95% CI, 7.8-10.0 vs 18.6; P < .001). The differences in age, mortality, and coronary artery disease remained when studies recruiting only from the United States were considered. Diabetes was more common in RCT participants from the United States than in the registry population.

CONCLUSIONS AND RELEVANCE

Participants in large, multicenter RCTs of patients with end-stage kidney disease undergoing dialysis are younger, have a different pattern of comorbidities, and have a lower mortality rate than the general population of patients undergoing dialysis. This finding has implications for the generalization of trial results to the broader patient population and for future trial design.

Decline in serum uric acid predicts higher risk for mortality in peritoneal dialysis patients-a propensity score analysis

BACKGROUND

The level of serum uric acid (SUA) in treatment follow-up is associated with mortality in peritoneal dialysis (PD) patients, but it remains unknown if the longitudinal change in SUA affects mortality.

METHODS

309 PD patients who were not using UA-lowering agents were enrolled. The longitudinal change in SUA was estimated by comparing the values between the run-in and follow-up periods. Based the calculated values, the patients were divided into SUA decliner and SUA non-decliner. A propensity score (PS) was calculated using the parameters measured in run-in period. After PS matching, the time-to-event analysis was performed for all-cause death.

RESULTS

After PS matching, 86 patients of each group were left. A higher mortality of 19/86 existed in SUA decliner compared with SUA non-decliner which is 3/86 (p < 0.001). Kaplan-Meier analysis in sub-cohort showed worse survival in the SUA decliner. Standard and stratified Cox regression analysis both showed SUA decline to be an independent risk factor for all-cause death in PD patients.

CONCLUSIONS

The decline in SUA in the follow-up may predict the all-cause mortality of PD patients, the reason of which may result from reducing scavenging effects of SUA or may reflect general condition. More studies need to be done.

Serum uric acid and cardiovascular mortality in chronic kidney disease: a meta-analysis

Background

Conflicting results have been reported from studies evaluating serum uric acid (SUA) levels as an independent risk factor for cardiovascular mortality in patients with chronic kidney disease (CKD).

Methods

We systematically searched MEDLINE, Web of Science, and bibliographies of retrieved articles to identify studies reporting on the association between SUA levels and cardiovascular mortality in patients with CKD. Random-effects models were used to calculate the pooled hazard ratios (HR) and corresponding 95% confidence intervals (CI).

Results

We included 11 studies with an overall sample of 27,081 patients with CKD in this meta-analysis. By meta-analysis, restricted to 7 studies (n = 11,050), patients with the highest SUA were associated with an increased risk of cardiovascular mortality (HR 1.47, 95% CI 1.11–1.96) compared with patients with the lowest SUA. There was no indication of publication bias or significant heterogeneity (I² = 40.4%; P = 0.109). Meta-analysis of 10 studies (n = 26,660) indicated that every 1 mg/dl increase in SUA levels increased a 12% risk in cardiovascular mortality (HR 1.12, 95% CI 1.02–1.24), with significant heterogeneity (I² = 79.2%, P < 0.001).

Conclusions

Higher SUA levels are associated with significantly increased risk of cardiovascular mortality in patients with CKD. More designed studies, especially randomized controlled trials, should be conducted to determine whether high SUA levels is a potentially modifiable risk factor for cardiovascular mortality in patients with CKD.

Electronic supplementary material

The online version of this article (10.1186/s12882-018-1143-7) contains supplementary material, which is available to authorized users.

Deleting Death and Dialysis: Conservative Care of Cardio-Vascular Risk and Kidney Function Loss in Chronic Kidney Disease (CKD)

The uremic syndrome, which is the clinical expression of chronic kidney disease (CKD), is a complex amalgam of accelerated aging and organ dysfunctions, whereby cardio-vascular disease plays a capital role. In this narrative review, we offer a summary of the current conservative (medical) treatment options for cardio-vascular and overall morbidity and mortality risk in CKD. Since the progression of CKD is also associated with a higher cardio-vascular risk, we summarize the interventions that may prevent the progression of CKD as well. We pay attention to established therapies, as well as to novel promising options. Approaches that have been considered are not limited to pharmacological approaches but take into account lifestyle measures and diet as well. We took as many randomized controlled hard endpoint outcome trials as possible into account, although observational studies and post hoc analyses were included where appropriate. We also considered health economic aspects. Based on this information, we constructed comprehensive tables summarizing the available therapeutic options and the number and kind of studies (controlled or not, contradictory outcomes or not) with regard to each approach. Our review underscores the scarcity of well-designed large controlled trials in CKD. Nevertheless, based on the controlled and observational data, a therapeutic algorithm can be developed for this complex and multifactorial condition. It is likely that interventions should be aimed at targeting several modifiable factors simultaneously.

Biochemical and Clinical Impact of Organic Uremic Retention Solutes: A Comprehensive Update

In this narrative review, the biological/biochemical impact (toxicity) of a large array of known individual uremic retention solutes and groups of solutes is summarized. We classified these compounds along their physico-chemical characteristics as small water-soluble compounds or groups, protein bound compounds and middle molecules. All but one solute (glomerulopressin) affected at least one mechanism with the potential to contribute to the uremic syndrome. In general, several mechanisms were influenced for each individual solute or group of solutes, with some impacting up to 7 different biological systems of the 11 considered. The inflammatory, cardio-vascular and fibrogenic systems were those most frequently affected and they are one by one major actors in the high morbidity and mortality of CKD but also the mechanisms that have most frequently been studied. A scoring system was built with the intention to classify the reviewed compounds according to the experimental evidence of their toxicity (number of systems affected) and overall experimental and clinical evidence. Among the highest globally scoring solutes were 3 small water-soluble compounds [asymmetric dimethylarginine (ADMA); trimethylamine-N-oxide (TMAO); uric acid], 6 protein bound compounds or groups of protein bound compounds [advanced glycation end products (AGEs); p-cresyl sulfate; indoxyl sulfate; indole acetic acid; the kynurenines; phenyl acetic acid;] and 3 middle molecules [β₂-microglobulin; ghrelin; parathyroid hormone). In general, more experimental data were provided for the protein bound molecules but for almost half of them clinical evidence was missing in spite of robust experimental data. The picture emanating is one of a complex disorder, where multiple factors contribute to a multisystem complication profile, so that it seems of not much use to pursue a decrease of concentration of a single compound.

Serum uric acid and mortality in chronic kidney disease: A systematic review and meta-analysis

BACKGROUND

Studies have shown inconsistent results about the association between serum uric acid levels and mortality in patients with chronic kidney disease (CKD).

METHODS

A systematic literature search in MEDLINE, Web of Science and bibliographies of retrieved articles was performed to identify studies investigating the association between serum uric acid and mortality in patients with CKD. Pooled hazard ratios (HR) and corresponding 95% confidence intervals (CIs) were calculated using random-effects models.

RESULTS

A total of 24 studies with 25,453 patients with CKD were included. By meta-analysis, patients with the highest serum uric acid level were associated with a significantly higher risk for mortality (14 studies; HR, 1.52; 95% CI, 1.33-1.73) compared with patients with the lowest serum uric acid level. For dose-response analysis, a linear relationship (8 studies; Pfor non-linearity=0.14) between serum uric acid levels and risk of mortality was found. Overall, an increase of 1mg/dl in serum uric acid level was associated with an 8% increased risk of mortality (21 studies; HR, 1.08; 95% CI, 1.04-1.11).

CONCLUSIONS

Elevated serum uric acid levels are significantly associated with risk of mortality in patients with CKD. Further randomized controlled trials should attempt to determine whether it improves survival to target serum uric acid in patients with CKD.

Lower serum uric acid level predicts mortality in dialysis patients

We evaluated the impact of serum uric acid (SUA) on mortality in patients with chronic dialysis. A total of 4132 adult patients on dialysis were enrolled prospectively between August 2008 and September 2014. Among them, we included 1738 patients who maintained dialysis for at least 3 months and had available SUA in the database. We categorized the time averaged-SUA (TA-SUA) into 5 groups: <5.5, 5.5-6.4, 6.5-7.4, 7.5-8.4, and ≥8.5 mg/dL. Cox regression analysis was used to calculate the hazard ratio (HR) of all-cause mortality according to SUA group. The mean TA-SUA level was slightly higher in men than in women. Patients with lower TA-SUA level tended to have lower body mass index (BMI), phosphorus, serum albumin level, higher proportion of diabetes mellitus (DM), and higher proportion of malnourishment on the subjective global assessment (SGA). During a median follow-up of 43.9 months, 206 patients died. Patients with the highest SUA had a similar risk to the middle 3 TA-SUA groups, but the lowest TA-SUA group had a significantly elevated HR for mortality. The lowest TA-SUA group was significantly associated with increased all-cause mortality (adjusted HR, 1.720; 95% confidence interval, 1.007-2.937; P = 0.047) even after adjusting for demographic, comorbid, nutritional covariables, and medication use that could affect SUA levels. This association was prominent in patients with well nourishment on the SGA, a preserved serum albumin level, a higher BMI, and concomitant DM although these parameters had no significant interaction in the TA-SUA-mortality relationship except DM. In conclusion, a lower TA-SUA level <5.5 mg/dL predicted all-cause mortality in patients with chronic dialysis.

Serum uric acid predicts cardiovascular mortality in male peritoneal dialysis patients with diabetes

BACKGROUND AND AIMS

Serum uric acid may predict mortality in diabetic patients and dialysis patients. However, the relationship between serum uric acid and prognosis in diabetic peritoneal dialysis (PD) patients is unclear.

METHODS AND RESULTS

We conducted a cohort study of 1278 incident PD patients, (mean age 47.6 years), of which 328 (25.7%) had diabetes and 289 (22.6%) had diabetic nephropathy. During a median follow-up period of 30.7 months, 231 deaths occurred, of which 126 were ascribed to cardiovascular events. Mean serum uric acid was lower for diabetic patients than non-diabetic patients (6.8 ± 1.3 vs. 7.4 ± 1.4 mg/dL, respectively; P < 0.001). Cox regression models were adjusted for glycated hemoglobin, dialysis-related factors, traditional risk factors, and treatments. After adjustments, the highest sex-specific tertile of uric acid was associated with an increased risk of cardiovascular mortality (HR, 2.26; 95% CI, 1.14-4.48) compared to the lowest tertile in diabetic patients. Adjusted HRs per 1 mg/dL higher uric acid for all-cause and cardiovascular mortality were 1.09 (95% CI, 0.91-1.32) and 1.42 (95% CI, 1.13-1.79) for diabetic men and 1.06 (95% CI, 0.83-1.35) and 1.12 (95% CI, 0.78-1.61) for diabetic women, respectively. Elevated serum uric acid predicted a higher risk of all-cause and cardiovascular mortality in non-diabetic men but not in non-diabetic women.

CONCLUSIONS

Elevated serum uric acid is an independent predictor of cardiovascular mortality in diabetic male PD patients.