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Zhou J, Zhang M, Xie Q, Xu N, Li M, Zhang M, Hao C. Recurrent exercise-induced acute kidney injury associated with hypouricemia: a case report and literature review. BMC Nephrol 2023; 24:384. [PMID: 38129773 PMCID: PMC10740252 DOI: 10.1186/s12882-023-03378-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 10/26/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Hereditary renal hypouricemia (RHUC) is a heterogenous disorder characterized by defective uric acid (UA) reabsorption resulting in hypouricemia and increased fractional excretion of UA. RHUC is an important cause of exercise-induced acute kidney injury (EIAKI), nephrolithiasis and posterior reversible encephalopathy syndrome (PRES). We present here an unusual case of a patient with RHUC who presented with recurrent EIAKI and had two heterozygous mutations in the SLC2A9 gene. CASE PRESENTATION A 43-year old man was admitted to our clinic because of bilateral loin pain, nausea and sleeplessness for 3 days after strenuous exercise. The laboratory results revealed increased levels of blood urea nitrogen (BUN) (15 mmol/l) and serum creatinine (Scr) (450 μmol/l), while the UA level was extremely low at 0.54 mg/dl, and his fractional excretion of urate (FE-UA) was 108%. The patient had an episode of acute kidney injury after playing soccer approximately 20 years ago, and on routine physical examination, his UA was less than 0.50 mg/dl. In view of the marked hypouricemia and high FE-UA, a diagnosis of RHUC was suspected, which led us to perform mutational screening of the SLC22A12 and SLC2A9 genes. DNA sequencing revealed no mutation in SLC22A12 gene, but two heterozygous mutations in the SLC2A9 gene. CONCLUSIONS This is a rare report of a patient with RHUC2 due to the mutation of SLC2A9. And this unique symptom of EIAKI and decreased or normal serum concentrations of UA warrant more attention as an early cue of RHUC.
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Affiliation(s)
- Jie Zhou
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
- Department of Nephrology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Min Zhang
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China.
| | - Qionghong Xie
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Ningxin Xu
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Mingxin Li
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Ming Zhang
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Chuanming Hao
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
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2
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Nakayama A, Kurajoh M, Toyoda Y, Takada T, Ichida K, Matsuo H. Dysuricemia. Biomedicines 2023; 11:3169. [PMID: 38137389 PMCID: PMC10740884 DOI: 10.3390/biomedicines11123169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 11/16/2023] [Accepted: 11/21/2023] [Indexed: 12/24/2023] Open
Abstract
Gout results from elevated serum urate (SU) levels, or hyperuricemia, and is a globally widespread and increasingly burdensome disease. Recent studies have illuminated the pathophysiology of gout/hyperuricemia and its epidemiology, diagnosis, treatment, and complications. The genetic involvement of urate transporters and enzymes is also proven. URAT1, a molecular therapeutic target for gout/hyperuricemia, was initially derived from research into hereditary renal hypouricemia (RHUC). RHUC is often accompanied by complications such as exercise-induced acute kidney injury, which indicates the key physiological role of uric acid. Several studies have also revealed its physiological role as both an anti-oxidant and a pro-oxidant, acting as both a scavenger and a generator of reactive oxygen species (ROSs). These discoveries have prompted research interest in SU and xanthine oxidoreductase (XOR), an enzyme that produces both urate and ROSs, as status or progression biomarkers of chronic kidney disease and cardiovascular disease. The notion of "the lower, the better" is therefore incorrect; a better understanding of uric acid handling and metabolism/transport comes from an awareness that excessively high and low levels both cause problems. We summarize here the current body of evidence, demonstrate that uric acid is much more than a metabolic waste product, and finally propose the novel disease concept of "dysuricemia" on the path toward "normouricemia", or optimal SU level, to take advantage of the dual roles of uric acid. Our proposal should help to interpret the spectrum from hypouricemia to hyperuricemia/gout as a single disease category.
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Affiliation(s)
- Akiyoshi Nakayama
- Department of Integrative Physiology and Bio-Nano Medicine, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Masafumi Kurajoh
- Department of Metabolism, Endocrinology and Molecular Medicine, Graduate School of Medicine, Osaka Metropolitan University, Osaka 545-8585, Japan
| | - Yu Toyoda
- Department of Integrative Physiology and Bio-Nano Medicine, National Defense Medical College, Tokorozawa 359-8513, Japan
- Department of Pharmacy, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Tappei Takada
- Department of Pharmacy, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Kimiyoshi Ichida
- Department of Pathophysiology, Tokyo University of Pharmacy and Life Science, Hachioji 192-0392, Japan
| | - Hirotaka Matsuo
- Department of Integrative Physiology and Bio-Nano Medicine, National Defense Medical College, Tokorozawa 359-8513, Japan
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3
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Aizawa C, Okabe M, Takahashi D, Sagasaki M, Watanabe M, Fujimoto T, Yoshioka Y, Katsuma A, Kimura A, Miyamoto D, Sato N, Okamoto K, Ichida K, Miyazaki Y, Yokoo T. Possible Use of Non-purine Selective Xanthine Oxidoreductase Inhibitors for Prevention of Exercise-induced Acute Kidney Injury Associated with Renal Hypouricemia. Intern Med 2023; 62:2725-2730. [PMID: 36754409 PMCID: PMC10569912 DOI: 10.2169/internalmedicine.0678-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 01/04/2023] [Indexed: 02/10/2023] Open
Abstract
Exercise-induced acute kidney injury (EIAKI) is frequently complicated with renal hypouricemia (RHUC). In patients with RHUC, limiting anaerobic exercise can prevent EIAKI. However, it is challenging to reduce exercise intensity in athletes. We herein report a 16-year-old Japanese football player with familial RHUC with compound heterozygous mutations in urate transporter 1 (URAT1) who presented with recurrent EIAKI. As prophylaxis (hydration during exercise) could not prevent EIAKI, febuxostat was initiated. EIAKI was not observed for 16 months despite exercising intensively. Hence, non-purine-selective xanthine oxidoreductase inhibitors may decrease the incidence of EIAKI in athletes with RHUC.
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Affiliation(s)
- Chiharu Aizawa
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Japan
| | - Masahiro Okabe
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Japan
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University Daisan Hospital, Japan
| | | | - Makoto Sagasaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Japan
- Department of Nephrology and Hypertension, Atsugi City Hospital, Japan
| | - Mao Watanabe
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Japan
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University Daisan Hospital, Japan
| | - Toshinari Fujimoto
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Japan
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University Daisan Hospital, Japan
| | - Yuuki Yoshioka
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Japan
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University Daisan Hospital, Japan
| | - Ai Katsuma
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Japan
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University Daisan Hospital, Japan
| | - Ai Kimura
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Japan
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University Daisan Hospital, Japan
| | - Daisuke Miyamoto
- Department of Endocrinology, Metabolism and Nephrology, Graduate School of Medicine, Nippon Medical School, Japan
| | - Nana Sato
- Department of Applied Biological Chemistry, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Japan
| | - Ken Okamoto
- Department of Applied Biological Chemistry, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Japan
| | - Kimiyoshi Ichida
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Japan
- Department of Pathophysiology, Faculty of Pharmaceutical Sciences, Tokyo University of Pharmacy and Life Sciences, Japan
| | - Yoichi Miyazaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Japan
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University Daisan Hospital, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Japan
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University Daisan Hospital, Japan
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4
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Miake J, Hisatome I, Tomita K, Isoyama T, Sugihara S, Kuwabara M, Ogino K, Ninomiya H. Impact of Hyper- and Hypo-Uricemia on Kidney Function. Biomedicines 2023; 11:biomedicines11051258. [PMID: 37238929 DOI: 10.3390/biomedicines11051258] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 04/18/2023] [Accepted: 04/19/2023] [Indexed: 05/28/2023] Open
Abstract
Uric acid (UA) forms monosodium urate (MSU) crystals to exert proinflammatory actions, thus causing gout arthritis, urolithiasis, kidney disease, and cardiovascular disease. UA is also one of the most potent antioxidants that suppresses oxidative stress. Hyper andhypouricemia are caused by genetic mutations or polymorphism. Hyperuricemia increases urinary UA concentration and is frequently associated with urolithiasis, which is augmented by low urinary pH. Renal hypouricemia (RHU) is associated with renal stones by increased level of urinary UA, which correlates with the impaired tubular reabsorption of UA. Hyperuricemia causes gout nephropathy, characterized by renal interstitium and tubular damage because MSU precipitates in the tubules. RHU is also frequently associated with tubular damage with elevated urinary beta2-microglobulin due to increased urinary UA concentration, which is related to impaired tubular UA reabsorption through URAT1. Hyperuricemia could induce renal arteriopathy and reduce renal blood flow, while increasing urinary albumin excretion, which is correlated with plasma xanthine oxidoreductase (XOR) activity. RHU is associated with exercise-induced kidney injury, since low levels of SUA could induce the vasoconstriction of the kidney and the enhanced urinary UA excretion could form intratubular precipitation. A U-shaped association of SUA with organ damage is observed in patients with kidney diseases related to impaired endothelial function. Under hyperuricemia, intracellular UA, MSU crystals, and XOR could reduce NO and activate several proinflammatory signals, impairing endothelial functions. Under hypouricemia, the genetic and pharmacological depletion of UA could impair the NO-dependent and independent endothelial functions, suggesting that RHU and secondary hypouricemia might be a risk factor for the loss of kidney functions. In order to protect kidney functions in hyperuricemic patients, the use of urate lowering agents could be recommended to target SUA below 6 mg/dL. In order to protect the kidney functions in RHU patients, hydration and urinary alkalization may be recommended, and in some cases an XOR inhibitor might be recommended in order to reduce oxidative stress.
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Affiliation(s)
- Junichiro Miake
- Division of Pharmacology, Department of Pathophysiological and Therapeutic Science, Tottori University Faculty of Medicine, Tottori 683-8503, Japan
| | - Ichiro Hisatome
- Department of Cardiology, Yonago Medical Center, Tottori 683-0006, Japan
| | - Katsuyuki Tomita
- Department of Respiratory Disease, Yonago Medical Center, Tottori 683-0006, Japan
| | - Tadahiro Isoyama
- Department of Urology, Yonago Medical Center, Tottori 683-0006, Japan
| | - Shinobu Sugihara
- Health Service Center, Shimane University, Matsue 690-0823, Japan
| | - Masanari Kuwabara
- Intensive Care Unit and Department of Cardiology, Toranomon Hospital, Tokyo 105-8470, Japan
| | - Kazuhide Ogino
- Department of Cardiology, Tottori Red Cross Hospital, Tottori 680-0017, Japan
| | - Haruaki Ninomiya
- Department of Biological Regulation, Tottori University Faculty of Medicine, Tottori 683-8503, Japan
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5
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Tadokoro T, Tamura Y, Mohri M. Response to: Hypouricaemia and acute kidney injury: a hereditary condition should be considered. QJM 2023; 116:252. [PMID: 35199163 DOI: 10.1093/qjmed/hcac059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- T Tadokoro
- From the Department of Internal Medicine, Japan Community Healthcare Organization Kyushu Hospital, 1-8-1, Kishinoura, Yahatanishi-ku, Kitakyushu, Fukuoka 806-8501, Japan
| | - Y Tamura
- From the Department of Internal Medicine, Japan Community Healthcare Organization Kyushu Hospital, 1-8-1, Kishinoura, Yahatanishi-ku, Kitakyushu, Fukuoka 806-8501, Japan
| | - M Mohri
- From the Department of Internal Medicine, Japan Community Healthcare Organization Kyushu Hospital, 1-8-1, Kishinoura, Yahatanishi-ku, Kitakyushu, Fukuoka 806-8501, Japan
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6
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Toyoda Y, Cho SK, Tasic V, Pavelcová K, Bohatá J, Suzuki H, David VA, Yoon J, Pallaiova A, Šaligová J, Nousome D, Cachau R, Winkler CA, Takada T, Stibůrková B. Identification of a dysfunctional exon-skipping splice variant in GLUT9/ SLC2A9 causal for renal hypouricemia type 2. Front Genet 2023; 13:1048330. [PMID: 36733941 PMCID: PMC9887137 DOI: 10.3389/fgene.2022.1048330] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 12/21/2022] [Indexed: 01/18/2023] Open
Abstract
Renal hypouricemia (RHUC) is a pathological condition characterized by extremely low serum urate and overexcretion of urate in the kidney; this inheritable disorder is classified into type 1 and type 2 based on causative genes encoding physiologically-important urate transporters, URAT1 and GLUT9, respectively; however, research on RHUC type 2 is still behind type 1. We herein describe a typical familial case of RHUC type 2 found in a Slovak family with severe hypouricemia and hyperuricosuria. Via clinico-genetic analyses including whole exome sequencing and in vitro functional assays, we identified an intronic GLUT9 variant, c.1419+1G>A, as the causal mutation that could lead the expression of p.Gly431GlufsTer28, a functionally-null variant resulting from exon 11 skipping. The causal relationship was also confirmed in another unrelated Macedonian family with mild hypouricemia. Accordingly, non-coding regions should be also kept in mind during genetic diagnosis for hypouricemia. Our findings provide a better pathogenic understanding of RHUC and pathophysiological importance of GLUT9.
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Affiliation(s)
- Yu Toyoda
- Department of Pharmacy, The University of Tokyo Hospital, Tokyo, Japan
| | - Sung Kweon Cho
- Molecular Genetics Epidemiology Section, Basic Research Laboratory, National Cancer Institute and Frederick National Laboratory for Cancer Research, Frederick, MD, United States,Department of Pharmacology, Ajou University School of Medicine, Suwon, South Korea
| | - Velibor Tasic
- Faculty of Medicine, University Ss. Cyril and Methodius, Skopje, North Macedonia
| | | | | | - Hiroshi Suzuki
- Department of Pharmacy, The University of Tokyo Hospital, Tokyo, Japan
| | - Victor A. David
- Department of Pharmacy, The University of Tokyo Hospital, Tokyo, Japan
| | - Jaeho Yoon
- Cancer and Developmental Biology Laboratory, Center for Cancer Research, National Cancer Institute, Frederick, MD, United States
| | | | - Jana Šaligová
- Metabolic Clinic, Children’s Faculty Hospital, Košice, Slovakia
| | - Darryl Nousome
- CCR Collaborative Bioinformatics Resource, Center for Cancer Research, National Cancer Institute, Frederick, MD, United States
| | - Raul Cachau
- Integrated Data Science Section, Research Technologies Branch, National Institute of Allergies and Infectious Diseases, Bethesda, MD, United States
| | - Cheryl A. Winkler
- Molecular Genetics Epidemiology Section, Basic Research Laboratory, National Cancer Institute and Frederick National Laboratory for Cancer Research, Frederick, MD, United States
| | - Tappei Takada
- Department of Pharmacy, The University of Tokyo Hospital, Tokyo, Japan
| | - Blanka Stibůrková
- Institute of Rheumatology, Prague, Czechia,Department of Rheumatology, First Faculty of Medicine, Charles University, Prague, Czechia,Department of Pediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia,*Correspondence: Blanka Stibůrková,
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7
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Genetic Basis of the Epidemiological Features and Clinical Significance of Renal Hypouricemia. Biomedicines 2022; 10:biomedicines10071696. [PMID: 35885001 PMCID: PMC9313227 DOI: 10.3390/biomedicines10071696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/08/2022] [Accepted: 07/11/2022] [Indexed: 11/17/2022] Open
Abstract
A genetic defect in urate transporter 1 (URAT1) is the major cause of renal hypouricemia (RHUC). Although RHUC is detected using a serum uric acid (UA) concentration <2.0 mg/dL, the relationship between the genetic state of URAT1 and serum UA concentration is not clear. Homozygosity and compound heterozygosity with respect to mutant URAT1 alleles are associated with a serum UA concentration of <1.0 mg/dL and are present at a prevalence of ~0.1% in Japan. In heterozygous individuals, the prevalence of a serum UA of 1.1−2.0 mg/dL is much higher in women than in men. The frequency of mutant URAT1 alleles is as high as 3% in the general Japanese population. The expansion of a specific mutant URAT1 allele derived from a single mutant gene that occurred in ancient times is reflected in modern Japan at a high frequency. Similar findings were reported in Roma populations in Europe. These phenomena are thought to reflect the ancient migration history of each ethnic group (founder effects). Exercise-induced acute kidney injury (EI-AKI) is mostly observed in individuals with homozygous/compound heterozygous URAT1 mutation, and laboratory experiments suggested that a high UA load on the renal tubules is a plausible mechanism for EI-AKI.
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Miyamoto D, Sato N, Nagata K, Sakai Y, Sugihara H, Ohashi Y, Stiburkova B, Sebesta I, Ichida K, Okamoto K. Analysis of Purine Metabolism to Elucidate the Pathogenesis of Acute Kidney Injury in Renal Hypouricemia. Biomedicines 2022; 10:biomedicines10071584. [PMID: 35884889 PMCID: PMC9312704 DOI: 10.3390/biomedicines10071584] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/27/2022] [Accepted: 06/28/2022] [Indexed: 12/02/2022] Open
Abstract
Renal hypouricemia is a disease caused by the dysfunction of renal urate transporters. This disease is known to cause exercise-induced acute kidney injury, but its mechanism has not yet been established. To analyze the mechanism by which hypouricemia causes renal failure, we conducted a semi-ischemic forearm exercise stress test to mimic exercise conditions in five healthy subjects, six patients with renal hypouricemia, and one patient with xanthinuria and analyzed the changes in purine metabolites. The results showed that the subjects with renal hypouricemia had significantly lower blood hypoxanthine levels and increased urinary hypoxanthine excretion after exercise than healthy subjects. Oxidative stress markers did not differ between healthy subjects and hypouricemic subjects before and after exercise, and no effect of uric acid as a radical scavenger was observed. As hypoxanthine is a precursor for adenosine triphosphate (ATP) production via the salvage pathway, loss of hypoxanthine after exercise in patients with renal hypouricemia may cause ATP loss in the renal tubules and consequent tissue damage.
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Affiliation(s)
- Daisuke Miyamoto
- Department of Nephrology, Graduate School of Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (D.M.); (Y.S.)
| | - Nana Sato
- Department of Applied Biological Chemistry, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo 113-8657, Japan; (N.S.); (K.N.)
| | - Koji Nagata
- Department of Applied Biological Chemistry, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo 113-8657, Japan; (N.S.); (K.N.)
| | - Yukinao Sakai
- Department of Nephrology, Graduate School of Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (D.M.); (Y.S.)
| | - Hitoshi Sugihara
- Department of Endocrinology, Diabetes, and Metabolism, Graduate School of Medicine, Nippon Medical School, Tokyo 113-8603, Japan;
| | - Yuki Ohashi
- Department of Pathophysiology, Tokyo University of Pharmacy and Life Sciences, Tokyo 192-0392, Japan; (Y.O.); (K.I.)
| | - Blanka Stiburkova
- Department of Pediatrics and Adolescent Medicine, First Faculty of Medicine, Charles University and General University Hospital, 11000 Prague, Czech Republic;
| | - Ivan Sebesta
- Institute of Rheumatology, Institute of Medical Biochemistry and Laboratory Diagnostics, First Faculty of Medicine, Charles University and General University Hospital, 11000 Prague, Czech Republic;
| | - Kimiyoshi Ichida
- Department of Pathophysiology, Tokyo University of Pharmacy and Life Sciences, Tokyo 192-0392, Japan; (Y.O.); (K.I.)
- Division of Kidney and Hypertension, Jikei University School of Medicine, Tokyo 105-8461, Japan
| | - Ken Okamoto
- Department of Applied Biological Chemistry, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo 113-8657, Japan; (N.S.); (K.N.)
- Correspondence: ; Tel.: +81-3-5841-5035
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9
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Otani N, Ouchi M, Misawa K, Hisatome I, Anzai N. Hypouricemia and Urate Transporters. Biomedicines 2022; 10:biomedicines10030652. [PMID: 35327453 PMCID: PMC8945357 DOI: 10.3390/biomedicines10030652] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 02/07/2023] Open
Abstract
Hypouricemia is recognized as a rare disorder, defined as a serum uric acid level of 2.0 mg/dL or less. Hypouricemia is divided into an overexcretion type and an underproduction type. The former typical disease is xanthinuria, and the latter is renal hypouricemia (RHUC). The frequency of nephrogenic hypouricemia due to a deficiency of URAT1 is high in Japan, accounting for most asymptomatic and persistent cases of hypouricemia. RHUC results in a high risk of exercise-induced acute kidney injury and urolithiasis. It is vital to promote research on RHUC, as this will lead not only to the elucidation of its pathophysiology but also to the development of new treatments for gout and hyperuricemia.
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Affiliation(s)
- Naoyuki Otani
- Department of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Oita University, Yufu 879-5593, Oita, Japan;
| | - Motoshi Ouchi
- Department of Pharmacology and Toxicology, Dokkyo Medical University School of Medicine, Mibu 321-0293, Tochigi, Japan;
| | - Kazuharu Misawa
- Department of Human Genetics, Yokohama City University Graduate School of Medicine, Yokohama 236-0004, Kanagawa, Japan;
| | - Ichiro Hisatome
- Yonago Medical Center, National Hospital Organization, Yonago 683-0006, Tottori, Japan;
- Department of Genetic Medicine and Regenerative Therapeutics, Institute of Regenerative Medicine and Biofunction, Graduate School of Medical Sciences, Tottori University, Yonago 680-8550, Tottori, Japan
| | - Naohiko Anzai
- Department of Pharmacology, Chiba University Graduate School of Medicine, Chiba 260-8670, Chiba, Japan
- Correspondence:
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10
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Hosoya T, Uchida S, Shibata S, Tomioka NH, Matsumoto K, Hosoyamada M. Xanthine Oxidoreductase Inhibitors Suppress the Onset of Exercise-Induced AKI in High HPRT Activity Urat1- Uox Double Knockout Mice. J Am Soc Nephrol 2022; 33:326-341. [PMID: 34799437 PMCID: PMC8819989 DOI: 10.1681/asn.2021050616] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 11/09/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Hereditary renal hypouricemia type 1 (RHUC1) is caused by URAT1/SLC22A12 dysfunction, resulting in urolithiasis and exercise-induced AKI (EIAKI). However, because there is no useful experimental RHUC1 animal model, the precise pathophysiologic mechanisms underlying EIAKI have yet to be elucidated. We established a high HPRT activity Urat1-Uox double knockout (DKO) mouse as a novel RHUC1 animal model for investigating the cause of EIAKI and the potential therapeutic effect of xanthine oxidoreductase inhibitors (XOIs). METHODS The novel Urat1-Uox DKO mice were used in a forced swimming test as loading exercise to explore the onset mechanism of EIAKI and evaluate related purine metabolism and renal injury parameters. RESULTS Urat1-Uox DKO mice had uricosuric effects and elevated levels of plasma creatinine and BUN as renal injury markers, and decreased creatinine clearance observed in a forced swimming test. In addition, Urat1-Uox DKO mice had increased NLRP3 inflammasome activity and downregulated levels of Na+-K+-ATPase protein in the kidney, as Western blot analysis showed. Finally, we demonstrated that topiroxostat and allopurinol, XOIs, improved renal injury and functional parameters of EIAKI. CONCLUSIONS Urat1-Uox DKO mice are a useful experimental animal model for human RHUC1. The pathogenic mechanism of EIAKI was found to be due to increased levels of IL-1β via NLRP3 inflammasome signaling and Na+-K+-ATPase dysfunction associated with excessive urinary urate excretion. In addition, XOIs appear to be a promising therapeutic agent for the treatment of EIAKI.
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Affiliation(s)
- Takuji Hosoya
- Department of Human Physiology and Pathology, Faculty of Pharma-Science, Teikyo University, Tokyo, Japan,Biological Research Department, Research Institute, Fuji Yakuhin Co., Ltd., Saitama, Japan
| | - Shunya Uchida
- Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Shigeru Shibata
- Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Naoko H. Tomioka
- Department of Human Physiology and Pathology, Faculty of Pharma-Science, Teikyo University, Tokyo, Japan
| | - Koji Matsumoto
- Biological Research Department, Research Institute, Fuji Yakuhin Co., Ltd., Saitama, Japan
| | - Makoto Hosoyamada
- Department of Human Physiology and Pathology, Faculty of Pharma-Science, Teikyo University, Tokyo, Japan
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Hypothetical Mechanism of Exercise-Induced Acute Kidney Injury Associated with Renal Hypouricemia. Biomedicines 2021; 9:biomedicines9121847. [PMID: 34944661 PMCID: PMC8698656 DOI: 10.3390/biomedicines9121847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 11/29/2021] [Accepted: 12/03/2021] [Indexed: 11/17/2022] Open
Abstract
Renal hypouricemia (RHUC) is a hereditary disease that presents with increased renal urate clearance and hypouricemia due to genetic mutations in the urate transporter URAT1 or GLUT9 that reabsorbs urates in the renal proximal tubule. Exercise-induced acute kidney injury (EIAKI) is known to be a complication of renal hypouricemia. In the skeletal muscle of RHUC patients during exhaustive exercise, the decreased release of endothelial-derived hyperpolarization factor (EDHF) due to hypouricemia might cause the disturbance of exercise hyperemia, which might increase post-exercise urinary urate excretion. In the kidneys of RHUC patients after exhaustive exercise, an intraluminal high concentration of urates in the proximal straight tubule and/or thick ascending limb of Henle’s loop might stimulate the luminal Toll-like receptor 4–myeloid differentiation factor 88–phosphoinositide 3-kinase–mammalian target of rapamycin (luminal TLR4–MyD88–PI3K–mTOR) pathway to activate the nucleotide-binding oligomerization domain-like receptor family pyrin domain-containing 3 (NLRP3) inflammasome and may release interleukin-1β (IL-1β), which might cause the symptoms of EIAKI.
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12
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Shoho M, Kuriyama A. Acute renal failure with severe loin pain and patchy renal ischemia after anaerobic exercise. Am J Emerg Med 2020; 43:291.e1-291.e3. [PMID: 33059989 DOI: 10.1016/j.ajem.2020.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 10/02/2020] [Accepted: 10/02/2020] [Indexed: 10/23/2022] Open
Abstract
Acute renal failure with severe loin pain and patchy renal ischemia after anaerobic exercise (ALPE) is gradually gaining recognition. In this case series, we describe the presentation of ALPE in the emergency department setting and its clinical course. In Case 1, an 18-year-old man presented with acute-onset nausea, vomiting, and right flank pain after playing basketball, with a creatinine level of 6.42 mg/dL on initial presentation. He received fluid therapy and intravenous furosemide for 2 days. His creatinine level was 1.80 mg/dL on day 8 and finally declined to 0.71 mg/dL on day 39. In Case 2, a 31-year-old man presented with acute-onset nausea and right lower abdominal pain after swimming, with a creatinine level of 4.68 mg/dL on initial presentation. He only received fluid therapy, and his creatinine level finally declined to 0.90 mg/dL on day 11. In both cases, severe loin pain began after anaerobic exercise, and acute kidney injury without myoglobinuria was observed. The findings of our case series suggest that emergency physicians should consider ALPE in the differential diagnosis of abdominal and loin pain accompanied by an elevated creatinine level in young patients because it can be treated conservatively and has a good prognosis. Moreover, watchful waiting is recommended for ALPE while also emphasizing the need to exclude potentially life threatening or treatable kidney diseases.
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Affiliation(s)
- Miyuki Shoho
- Emergency and Critical Care Center, Kurashiki Central Hospital, Japan
| | - Akira Kuriyama
- Emergency and Critical Care Center, Kurashiki Central Hospital, Japan.
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Tsuji K, Kitamura M, Muta K, Mochizuki Y, Mori T, Sohara E, Uchida S, Sakai H, Mukae H, Nishino T. Transplantation of a kidney with a heterozygous mutation in the SLC22A12 (URAT1) gene causing renal hypouricemia: a case report. BMC Nephrol 2020; 21:282. [PMID: 32677916 PMCID: PMC7364597 DOI: 10.1186/s12882-020-01940-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 07/08/2020] [Indexed: 11/10/2022] Open
Abstract
Background Renal hypouricemia (RHUC) is a genetic disorder caused by mutations in the SLC22A12 gene, which encodes the major uric acid (UA) transporter, URAT1. The clinical course of related, living donor-derived RHUC in patients undergoing kidney transplantation is poorly understood. Here, we report a case of kidney transplantation from a living relative who had an SLC22A12 mutation. After the transplantation, the recipient’s fractional excretion of UA (FEUA) decreased, and chimeric tubular epithelium was observed. Case presentation A 40-year-old man underwent kidney transplantation. His sister was the kidney donor. Three weeks after the transplantation, he had low serum-UA, 148.7 μmol/L, and elevated FEUA, 20.8% (normal: < 10%). The patient’s sister had low serum-UA (101.1 μmol/L) and high FEUA (15.8%) before transplant. Suspecting RHUC, we performed next-generation sequencing on a gene panel containing RHUC-associated genes. A heterozygous missense mutation in the SLC22A12 gene was detected in the donor, but not in the recipient. The recipient’s serum-UA level increased from 148.7 μmol/L to 231.9 μmol/L 3 months after transplantation and was 226.0 μmol/L 1 year after transplantation. His FEUA decreased from 20.8 to 11.7% 3 months after transplantation and was 12.4% 1 year after transplantation. Fluorescence in situ hybridization of allograft biopsies performed 3 months and 1 year after transplantation showed the presence of Y chromosomes in the tubular epithelial cells, suggesting the recipient’s elevated serum-UA levels were owing to a chimeric tubular epithelium. Conclusions We reported on a kidney transplant recipient that developed RHUC owing to his donor possessing a heterozygous mutation in the SLC22A12 (URAT1) gene. Despite this mutation, the clinical course was not problematic. Thus, the presence of donor-recipient chimerism in the tubular epithelium might positively affect the clinical course, at least in the short-term.
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Affiliation(s)
- Kiyokazu Tsuji
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Mineaki Kitamura
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan.
| | - Kumiko Muta
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yasushi Mochizuki
- Department of Urology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Takayasu Mori
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Eisei Sohara
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shinichi Uchida
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hideki Sakai
- Department of Urology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tomoya Nishino
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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Furuto Y, Kawamura M, Namikawa A, Takahashi H, Shibuya Y, Mori T, Sohara E. Non-urate transporter 1, non-glucose transporter member 9-related renal hypouricemia and acute renal failure accompanied by hyperbilirubinemia after anaerobic exercise: a case report. BMC Nephrol 2019; 20:433. [PMID: 31771519 PMCID: PMC6878684 DOI: 10.1186/s12882-019-1618-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 11/08/2019] [Indexed: 11/11/2022] Open
Abstract
Background Renal hypouricemia (RHUC) is an inherited heterogenous disorder caused by faulty urate reabsorption transporters in the renal proximal tubular cells. Anaerobic exercise may induce acute kidney injury in individuals with RHUC that is not caused by exertional rhabdomyolysis; it is called acute renal failure with severe loin pain and patchy renal ischemia after anaerobic exercise (ALPE). RHUC is the most important risk factor for ALPE. However, the mechanism of onset of ALPE in patients with RHUC has not been elucidated. The currently known genes responsible for RHUC are SLC22A12 and SLC2A9. Case presentation A 37-year-old man presented with loin pain after exercising. Despite having a healthy constitution from birth, biochemical examination revealed hypouricemia, with a uric acid (UA) level of < 1 mg/dL consistently at every health check. We detected acute kidney injury, with a creatinine (Cr) level of 4.1 mg/dL, and elevated bilirubin; hence, the patient was hospitalized. Computed tomography revealed no renal calculi, but bilateral renal swelling was noted. Magnetic resonance imaging detected cuneiform lesions, indicating bilateral renal ischemia. Fractional excretion values of sodium and UA were 0.61 and 50.5%, respectively. Urinary microscopy showed lack of tubular injury. The patient’s older sister had hypouricemia. The patient was diagnosed with ALPE. Treatment with bed rest, fluid replacement, and nutrition therapy improved renal function and bilirubin levels, and the patient was discharged on day 5. Approximately 1 month after onset of ALPE, his Cr, UA, and TB levels were 0.98, 0.8, and 0.9 mg/dL, respectively. We suspected familial RHUC due to the hypouricemia and family history and performed genetic testing but did not find the typical genes responsible for RHUC. A full genetic analysis was opposed by the family. Conclusions To the best of our knowledge, this is the first report of ALPE with hyperbilirubinemia. Bilirubin levels may become elevated as a result of heme oxygenase-1 activation, occurring in exercise-induced acute kidney injury in patients with RHUC; this phenomenon suggests renal ischemia-reperfusion injury. A new causative gene coding for a urate transporter may exist, and its identification would be useful to clarify the urate transport mechanism.
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Affiliation(s)
- Yoshitaka Furuto
- Department of Hypertension and Nephrology, NTT Medical Centre, Tokyo, 5-9-22, Higasi-Gotanda, Shinagawa-ku, Tokyo, 141-8625, Japan.
| | - Mariko Kawamura
- Department of Hypertension and Nephrology, NTT Medical Centre, Tokyo, 5-9-22, Higasi-Gotanda, Shinagawa-ku, Tokyo, 141-8625, Japan
| | - Akio Namikawa
- Department of Hypertension and Nephrology, NTT Medical Centre, Tokyo, 5-9-22, Higasi-Gotanda, Shinagawa-ku, Tokyo, 141-8625, Japan
| | - Hiroko Takahashi
- Department of Hypertension and Nephrology, NTT Medical Centre, Tokyo, 5-9-22, Higasi-Gotanda, Shinagawa-ku, Tokyo, 141-8625, Japan
| | - Yuko Shibuya
- Department of Hypertension and Nephrology, NTT Medical Centre, Tokyo, 5-9-22, Higasi-Gotanda, Shinagawa-ku, Tokyo, 141-8625, Japan
| | - Takayasu Mori
- Department of Nephrology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Eisei Sohara
- Department of Nephrology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
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Hypouricemia: what the practicing rheumatologist should know about this condition. Clin Rheumatol 2019; 39:135-147. [PMID: 31650389 DOI: 10.1007/s10067-019-04788-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 08/27/2019] [Accepted: 09/21/2019] [Indexed: 12/15/2022]
Abstract
We presented an update in the field of hypouricemia, which is defined as a serum urate concentration of < 2 mg/dL (119 μmol/L), for the practicing rheumatologist, who usually is the consulting physician in cases of disorders of urate metabolism. We performed a narrative review through a literature search for original and review articles in the field of human hypouricemia published between January 1950 and July 2018. We divided the etiology of hypouricemia into two main categories: those associated with a decrease in urate production and those promoting the elimination of urate via the kidneys. The most common conditions associated with these categories are discussed. Furthermore, the etiology of hypouricemia may be associated with certain medications prescribed by the practicing rheumatologists, such as the following: urate-lowering drugs (allopurinol and febuxostat); recombinant uricase (pegloticase); uricosuric agents (probenecid, benzbromarone); urate transporter URAT1 inhibitor (lesinurad); angiotensin II receptor blocker (losartan); fenofibrate; high-dose trimethoprim-sulfamethoxazole; some NSAID; and high-dose salicylate therapy. The rheumatologist is considered an expert in the metabolism of urate and its associated pathological conditions. Therefore, specialists must recognize hypouricemia as a biomarker of various pathological and potentially harmful conditions, highlighting the importance of conducting a deeper clinical investigation to reach a more accurate diagnosis and treatment.
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16
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Shimizu Y, Wakabayashi K, Totsuka A, Hayashi Y, Nitta S, Hara K, Akira M, Tomino Y, Suzuki Y. Exercise-Induced Acute Kidney Injury in a Police Officer with Hereditary Renal Hypouricemia. Case Rep Nephrol Dial 2019; 9:92-101. [PMID: 31602378 PMCID: PMC6738254 DOI: 10.1159/000501877] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 07/02/2019] [Indexed: 12/27/2022] Open
Abstract
Hereditary renal hypouricemia is characterized by hypouricemia with hyper-uric acid clearance due to a defect in renal tubular transport. Patients with hereditary renal hypouricemia have a higher risk of exercise-induced acute kidney injury (EAKI) and reduced kidney function. Although the best preventive measure is avoiding exercise, there are many kinds of jobs that require occupational exercise. A 27-year-old male police officer suffered from stage 3 AKI after performing a 20-m multistage shuttle run test. His mother had previously been diagnosed as having renal hypouricemia at another facility. The patient had reported having hypouricemia during a health check at a previous police station, but his serum uric acid concentration was within the normal range at our hospital. After treatment, he recovered from EAKI and exhibited low serum uric acid and hyper-uric acid clearance. Since the patient desired to continue his career requiring strenuous exercise, it was difficult to establish a preventive plan against the recurrence of EAKI. Patients with hereditary renal hypouricemia who must undergo strenuous occupational anaerobic exercise are at higher risk of developing EAKI than other workers. The risks of EAKI among patients with hypouricemia should be considered when undergoing physical occupational training.
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Affiliation(s)
- Yoshio Shimizu
- Division of Nephrology, Department of Internal Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan.,Shizuoka Medical Research Center for Disaster, Juntendo University, Tokyo, Japan
| | - Keiichi Wakabayashi
- Division of Nephrology, Department of Internal Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Ayako Totsuka
- Division of Nephrology, Department of Internal Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan.,Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Yoko Hayashi
- Division of Nephrology, Department of Internal Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Shusaku Nitta
- Division of Nephrology, Department of Internal Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Kazuaki Hara
- Division of Nephrology, Department of Internal Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Maiko Akira
- Division of Nephrology, Department of Internal Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Yasuhiko Tomino
- Asian Pacific Renal Research Promotion Office, Showakai Medical Corporation, Tokyo, Japan
| | - Yusuke Suzuki
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Juntendo University, Tokyo, Japan
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17
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Distribution and Characteristics of Hypouricemia within the Japanese General Population: A Cross-Sectional Study. ACTA ACUST UNITED AC 2019; 55:medicina55030061. [PMID: 30836687 PMCID: PMC6473785 DOI: 10.3390/medicina55030061] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 02/24/2019] [Accepted: 02/25/2019] [Indexed: 02/04/2023]
Abstract
Background and objectives: There is insufficient epidemiological knowledge of hypouricemia. In this study, we aimed to describe the distribution and characteristics of Japanese subjects with hypouricemia. Materials and Methods: Data from subjects who underwent routine health checkups from January 2001 to December 2015 were analyzed in this cross-sectional study. A total of 246,923 individuals, which included 111,117 men and 135,806 women, met the study criteria. The participants were divided into quartiles according to their serum uric acid (SUA) levels. We subdivided the subjects with hypouricemia, which was defined as SUA level ≤ 2.0 mg/dL, into two groups and compared their characteristics, including their cardiovascular risks. Results: The hypouricemia rates were 0.46% overall, 0.21% for the men and 0.66% for the women (P < 0.001). The number of the subjects with hypouricemia showed two distributions at SUA levels of 0.4–1.1 mg/dL (lower hypouricemia group), which included a peak at 0.7–0.8 mg/dL, and at SUA levels of 1.4–2.0 mg/dL (higher hypouricemia group). The men in the higher hypouricemia group had lower body mass indexes (BMI) and triglyceride (TG) levels and had higher fasting blood glucose levels than those in the lower hypouricemia group. The women in the higher hypouricemia group were younger; had lower BMI, total protein, TG, total cholesterol and low-density lipoprotein cholesterol levels; and had higher estimated glomerular filtration rates levels compared to those in the lower hypouricemia group. Conclusions: The characteristics of the individuals in the lower and higher hypouricemia groups differed significantly, indicating different pathophysiologies within each group.
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Nakayama A, Matsuo H, Ohtahara A, Ogino K, Hakoda M, Hamada T, Hosoyamada M, Yamaguchi S, Hisatome I, Ichida K, Shinomiya N. Clinical practice guideline for renal hypouricemia (1st edition). Hum Cell 2019; 32:83-87. [PMID: 30783949 PMCID: PMC6437292 DOI: 10.1007/s13577-019-00239-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 01/17/2019] [Indexed: 11/29/2022]
Abstract
Renal hypouricemia (RHUC) is a disease caused by dysfunction of renal urate reabsorption transporters; however, diagnostic guidance and guidelines for RHUC have been lacking, partly due to the low evidence level of studies on RHUC. This review describes a world-first clinical practice guideline (CPG) and its first version in English for this condition. It was developed following the "MINDS Manual for Guideline Development" methodology, which prioritizes evidence-based medicine. It was published in Japanese in 2017 and later translated into English. The primary goal of this CPG is to clarify the criteria for diagnosing RHUC; another aim is to work towards a consensus on clinical decision-making. One of the CPG's unique points is that it contains textbook descriptions at the expert consensus level, in addition to two clinical questions and recommendations derived from a systematic review of the literature. The guidance shown in this CPG makes it easy to diagnose RHUC from simple blood and urine tests. This CPG contains almost all of the clinical foci of RHUC: epidemiology, pathophysiology, diagnostic guidance, clinical examinations, differential diagnosis, and complications, including exercise-induced acute kidney injury and urolithiasis. A CPG summary as well as a clinical algorithm to assist healthcare providers with a quick reference and notes from an athlete for both physicians and patients are included. We hope that this CPG will help healthcare providers and patients to make clinical decisions, and that it will promote further research on RHUC.
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Affiliation(s)
- Akiyoshi Nakayama
- Department of Integrative Physiology and Bio-Nano Medicine, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan
- Medical Squadron, Air Base Group, Western Aircraft Control and Warning Wing, Japan Air Self-Defense Force, Kasuga, Japan
| | - Hirotaka Matsuo
- Department of Integrative Physiology and Bio-Nano Medicine, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Akira Ohtahara
- Division of Cardiology, Sanin Rosai Hospital, Yonago, Japan
| | - Kazuhide Ogino
- Department of Cardiology, Japanese Red Cross Tottori Hospital, Tottori, Japan
| | - Masayuki Hakoda
- Department of Nutritional Sciences, Faculty of Human Ecology, Yasuda Women's University, Hiroshima, Japan
| | - Toshihiro Hamada
- Department of Regional Medicine, Tottori University Faculty of Medicine, Tottori, Japan
| | - Makoto Hosoyamada
- Department of Human Physiology and Pathology, Faculty Pharma-Science, Teikyo University, Tokyo, Japan
| | - Satoshi Yamaguchi
- Department of Urology, The Urinary Stone Medical Center, Kitasaito Hospital, Asahikawa, Japan
| | - Ichiro Hisatome
- Department of Genetic Medicine and Regenerative Therapeutics, Institute of Regenerative Medicine and Biofunction, Tottori University Graduate School of Medical Science, Tottori, Japan
| | - Kimiyoshi Ichida
- Department of Pathophysiology, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Nariyoshi Shinomiya
- Department of Integrative Physiology and Bio-Nano Medicine, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan.
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Claverie-Martin F, Trujillo-Suarez J, Gonzalez-Acosta H, Aparicio C, Justa Roldan ML, Stiburkova B, Ichida K, Martín-Gomez MA, Herrero Goñi M, Carrasco Hidalgo-Barquero M, Iñigo V, Enriquez R, Cordoba-Lanus E, Garcia-Nieto VM. URAT1 and GLUT9 mutations in Spanish patients with renal hypouricemia. Clin Chim Acta 2018; 481:83-89. [PMID: 29486147 DOI: 10.1016/j.cca.2018.02.030] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 02/22/2018] [Accepted: 02/22/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND Renal hypouricemia (RHUC), a rare inherited disorder characterized by impaired uric acid (UA) reabsorption in the proximal tubule, is caused by mutations in SLC22A12 or SLC2A9. Most mutations have been identified in Japanese patients, and only a few have been detected in Europeans. METHODS We report clinical, biochemical and genetics findings of fourteen Spanish patients, six Caucasians and eight of Roma ethnia, diagnosed with idiopathic RHUC. Two of the patients presented exercise-induced acute renal failure and another one had several episodes of nephrolithiasis and four of them had progressive deterioration of renal function, while the rest were asymptomatic. RESULTS Molecular analysis revealed SLC22A12 mutations in ten of the patients, and SLC2A9 mutations in the other four. A new heterozygous SLC22A12 missense mutation, c.1427C>A (p.A476D), was identified in two affected members of the same family. The rest of the patients presented homozygous, heterozygous or compound heterozygous mutations that have been previously identified in patients with RHUC; SLC22A12 p.T467M and p.L415_G417del, and SLC2A9 p.T125M. Expression studies in Xenopus oocytes revealed that c.1427C>A reduced UA transport but did not alter the location of URAT1 protein on the plasma membrane. CONCLUSIONS The biochemical and clinical features of our patients together with the genetic analysis results confirmed the diagnosis of RHUC. This is the first report describing SLC22A12 and SLC2A9 mutations in Spanish patients.
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Affiliation(s)
- Felix Claverie-Martin
- Unidad de Investigación, Hospital Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain.
| | - Jorge Trujillo-Suarez
- Unidad de Investigación, Hospital Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Hilaria Gonzalez-Acosta
- Unidad de Investigación, Hospital Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | | | | | - Blanka Stiburkova
- Institute of Inherited Metabolic Disorders, Charles University, General University Hospital in Prague, Prague, Czech Republic; Institute of Rheumatology, Prague, Czech Republic
| | - Kimiyoshi Ichida
- Department of Pathophysiology, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | | | | | | | - Victoria Iñigo
- Unidad de Nefrología, Hospital Son Llàtzer, Palma de Mallorca, Spain
| | | | - Elizabeth Cordoba-Lanus
- Unidad de Investigación, Hospital Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Victor M Garcia-Nieto
- Unidad de Nefrología Pediatrica, Hospital Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
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Haga Y, Ohtsubo T, Murakami N, Noguchi H, Kansui Y, Goto K, Matsumura K, Kitazono T. Disruption of xanthine oxidoreductase gene attenuates renal ischemia reperfusion injury in mice. Life Sci 2017. [PMID: 28625358 DOI: 10.1016/j.lfs.2017.06.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
AIMS We examined the roles of xanthine oxidoreductase (XOR) in renal ischemia reperfusion (IR) injury. MAIN METHODS XOR+/+ and XOR+/- mice were subjected to 24-h reperfusion after a 45-min bilateral renal artery occlusion or sham operation. We evaluated the renal damage based on the concentrations of blood urea nitrogen (BUN) and serum creatinine (Cr), and histological changes were detected by PAS staining. Xanthine dehydrogenase, oxidase (XO) and XOR activities, amounts of blood and urine 8-OHdG, and expressions of TNF-α and MCP-1 mRNA were examined. F4/80 and nitrotyrosine-positive cells were assessed by immunohistochemical staining. KEY FINDINGS The BUN and Cr concentrations in the XOR+/+IR mice were increased significantly compared to those in XOR+/-IR and allopurinol-treated XOR+/+IR mice. XO and XOR activity, which were increased in IR mice, were reduced in the allopurinol-treated XOR+/+IR and XOR+/-IR mice compared to the XOR+/+IR mice. The concentrations of blood and urine 8-OHdG, and the expressions of MCP-1 and TNF-α mRNA were increased significantly in the XOR+/+IR mice compared to those in the XOR+/-IR mice. The histological analysis revealed that the XOR+/-IR and allopurinol-treated XOR+/+IR mice showed less tubular injury than the XOR+/+IR mice in the cortex regions, with the reduction of inflammation and oxidative stress assessed by the immunohistological staining for F4/80 and nitrotyrosine. SIGNIFICANCE Both the disruption of XOR gene in XOR+/- mice and the reduction of XOR activity in allopurinol-treated XOR+/+IR mice attenuated renal tissue injury in this IR model. Reduced XOR activity during renal IR could be a beneficial treatment target.
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Affiliation(s)
- Yoshie Haga
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Toshio Ohtsubo
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Noboru Murakami
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hideko Noguchi
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuo Kansui
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Internal Medicine, Fukuoka Dental College, Fukuoka, Japan
| | - Kenichi Goto
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kiyoshi Matsumura
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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21
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Sanchez-Niño MD, Zheng-Lin B, Valiño-Rivas L, Sanz AB, Ramos AM, Luño J, Goicoechea M, Ortiz A. Lesinurad: what the nephrologist should know. Clin Kidney J 2017; 10:679-687. [PMID: 28979780 PMCID: PMC5622894 DOI: 10.1093/ckj/sfx036] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 04/03/2017] [Indexed: 01/06/2023] Open
Abstract
Lesinurad is an oral inhibitor of the monocarboxylic/urate transporter URAT1 encoded by the SLC22A12 gene. Market authorization was granted in February 2016 in Europe and December 2015 in the USA. As a potentially nephrotoxic uricosuric drug acting on the kidney, nephrologists should become familiar with its indications and safety profile. The approved indication is treatment of gout in combination with a xanthine oxidase (XO) inhibitor in adult patients who have not achieved target serum uric acid levels with an XO inhibitor alone. It is not indicated for asymptomatic hyperuricaemia or for patients with estimated creatinine clearance <45 mL/min. The only authorized daily dose is 200 mg and cannot be exceeded because of the nephrotoxicity risk. Nephrotoxicity is thought to be related to uricosuria. At the 200 mg/day dose, serum creatinine more than doubled in 1.8% of lesinurad patients (versus 0% in placebo) and in 11% of these it was not reversible. In addition, it is subject to a risk management plan given the potential association with cardiovascular events. In randomized clinical trials, the association of lesinurad with either allopurinol or febuxostat achieved a greater reduction in serum uric acid (∼1 mg/dL lower) than the XO inhibitors alone, and this allowed the serum uric acid target to be met in a higher proportion of patients, which was the primary endpoint. However, no clinical differences were observed in gout flares or tophi, although these were not the primary endpoints.
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Affiliation(s)
- Maria Dolores Sanchez-Niño
- Department of Nephrology, IIS-Fundacion Jimenez Diaz, School of Medicine, Universidad Autonoma de Madrid, Madrid, Spain
- Fundacion Renal Iñigo Alvarez de Toledo (FRIAT), Madrid, Spain
- REDINREN, Madrid, Spain
| | - Binbin Zheng-Lin
- Department of Nephrology, IIS-Fundacion Jimenez Diaz, School of Medicine, Universidad Autonoma de Madrid, Madrid, Spain
- Fundacion Renal Iñigo Alvarez de Toledo (FRIAT), Madrid, Spain
| | - Lara Valiño-Rivas
- Department of Nephrology, IIS-Fundacion Jimenez Diaz, School of Medicine, Universidad Autonoma de Madrid, Madrid, Spain
- Fundacion Renal Iñigo Alvarez de Toledo (FRIAT), Madrid, Spain
- REDINREN, Madrid, Spain
| | - Ana Belen Sanz
- Department of Nephrology, IIS-Fundacion Jimenez Diaz, School of Medicine, Universidad Autonoma de Madrid, Madrid, Spain
- Fundacion Renal Iñigo Alvarez de Toledo (FRIAT), Madrid, Spain
- REDINREN, Madrid, Spain
| | - Adrian Mario Ramos
- Department of Nephrology, IIS-Fundacion Jimenez Diaz, School of Medicine, Universidad Autonoma de Madrid, Madrid, Spain
- Fundacion Renal Iñigo Alvarez de Toledo (FRIAT), Madrid, Spain
- REDINREN, Madrid, Spain
| | - Jose Luño
- REDINREN, Madrid, Spain
- Servicio de Nefrología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Marian Goicoechea
- REDINREN, Madrid, Spain
- Servicio de Nefrología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Alberto Ortiz
- Department of Nephrology, IIS-Fundacion Jimenez Diaz, School of Medicine, Universidad Autonoma de Madrid, Madrid, Spain
- Fundacion Renal Iñigo Alvarez de Toledo (FRIAT), Madrid, Spain
- REDINREN, Madrid, Spain
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Hosoyamada M, Tsurumi Y, Hirano H, Tomioka NH, Sekine Y, Morisaki T, Uchida S. Urat1-Uox double knockout mice are experimental animal models of renal hypouricemia and exercise-induced acute kidney injury. NUCLEOSIDES NUCLEOTIDES & NUCLEIC ACIDS 2017; 35:543-549. [PMID: 27906636 DOI: 10.1080/15257770.2016.1143559] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Renal hypouricemia (RHUC) is a hereditary disease characterized by a low level of plasma urate but with normal urinary urate excretion. RHUC type 1 is caused by mutations of the urate transporter URAT1 gene (SLC22A12). However, the plasma urate levels of URAT1 knockout mice are no different from those of wild-type mice. In the present study, a double knockout mouse, in which the URAT1 and uricase (Uox) genes were deleted (Urat1-Uox-DKO), were used as an experimental animal model of RHUC type 1 to investigate RHUC and excise-induced acute kidney injury (EIAKI). Mice were given a variable content of allopurinol for one week followed by HPLC measurement of urate and creatinine concentrations in spot urine and blood from the tail. The urinary excretion of urate in Urat1-Uox-DKO mice was approximately 25 times higher than those of humans. With allopurinol, the plasma urate levels of Urat1-Uox-DKO mice were lower than those of Uox-KO mice. There were no differences in the urinary urate excretions between Urat1-Uox-DKO and Uox-KO mice administered with 9 mg allopurinol /100 g feed. In the absence of allopurinol, plasma creatinine levels of some Urat1-Uox-DKO mice were higher than those of Uox-KO mice. Consequently, hypouricemia and normouricosuria may indicate that the Urat1-Uox-DKO mouse administered with allopurinol may represent a suitable animal model of RHUC type 1. Urat1-Uox-DKO mice without allopurinol exhibited acute kidney injury, thus providing additional benefit as a potential animal model for EIAKI. Finally, our data indicate that allopurinol appears to provide prophylactic effects for EIAKI.
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Affiliation(s)
- Makoto Hosoyamada
- a Department of Human Physiology & Pathology , Faculty of Pharma-Sciences, Teikyo University , Tokyo , Japan
| | - Yu Tsurumi
- b Department of Practical Pharmacology , Faculty and Graduate School of Pharmaceutical Sciences, Chiba University , Chiba , Japan
| | - Hidenori Hirano
- b Department of Practical Pharmacology , Faculty and Graduate School of Pharmaceutical Sciences, Chiba University , Chiba , Japan
| | - Naoko H Tomioka
- a Department of Human Physiology & Pathology , Faculty of Pharma-Sciences, Teikyo University , Tokyo , Japan
| | - Yuko Sekine
- b Department of Practical Pharmacology , Faculty and Graduate School of Pharmaceutical Sciences, Chiba University , Chiba , Japan
| | - Takayuki Morisaki
- c Department of Bioscience , National Cardiovascular Center Research Institute , Osaka , Japan
| | - Shunya Uchida
- d Department of Internal Medicine , Faculty of Medicine, Teikyo University , Tokyo , Japan
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A case of xanthinuria type I with a novel mutation in xanthine dehydrogenase. CEN Case Rep 2016; 5:158-162. [PMID: 28508967 DOI: 10.1007/s13730-016-0216-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 02/19/2016] [Indexed: 12/13/2022] Open
Abstract
Hereditary hypouricemia is generally caused by renal hypouricemia, an autosomal recessive disorder that is characterized by impaired renal tubular uric acid transport, or by xanthinuria, a rare autosomal recessive disorder caused by a deficiency of xanthine dehydrogenase (XDH; xanthinuria type I) or by a deficiency of both XDH and aldehyde oxidase (xanthinuria type II). In contrast to renal hypouricemia, which sometimes leads to exercise-induced acute kidney injury (EIAKI), xanthinuria has not been associated with this disorder. We report here a case of xanthinuria type I due to a compound heterozygous mutation. A 46-year-old woman was found to have undetectable plasma and urinary levels of uric acid. She had no symptoms and no history of EIAKI. Xanthinuria type I was diagnosed following the allopurinol loading test. Mutation analysis revealed a compound heterozygous mutation [c.305A>G (p.Gln102Arg) and c.2567delC (p.Thr856Lysfs*73)] in the XDH gene. Of these two mutations, the former is novel. The patient did not exhibit EIAKI. However, because xanthinuria is a rare disease, the identification of additional cases is necessary to determine whether this disease is complicated with EIAKI.
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Cui JW, Hou TJ, Wang Q, Gao GG, Bi S, Zhou KC, Li JL, Wu DM. An Enzyme Assisted Electrochemical Detection System of Purine Intracellular Utilizing MWCNTs-IL Modified Glassy Carbon Electrode. Electrochim Acta 2015. [DOI: 10.1016/j.electacta.2015.08.138] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Shen H, Feng C, Jin X, Mao J, Fu H, Gu W, Liu A, Shu Q, Du L. Recurrent exercise-induced acute kidney injury by idiopathic renal hypouricemia with a novel mutation in the SLC2A9 gene and literature review. BMC Pediatr 2014; 14:73. [PMID: 24628802 PMCID: PMC3984694 DOI: 10.1186/1471-2431-14-73] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 03/06/2014] [Indexed: 11/15/2022] Open
Abstract
Background Idiopathic renal hypouricemia (iRHUC) is an autosomal recessive hereditary disorder, characterized by impaired tubular uric acid transport, re-absorption insufficiency and/or the acceleration of secretions. Some patients present with severe complications, such as exercise-induced acute kidney injury (EIAKI) and nephrolithiasis. Case presentation Herein, we report the case of a girl with severe iRHUC (serum urate 0.05 mg/dL, fractional excretion of uric acid 295.99%) associated with recurrent EIAKI, in whom the disease was caused by a homozygous mutation (g.68G > A in exon 3) in the SLC2A9 gene. Her family members (father, mother and brother) carried the same mutation but were heterozygous, without any signs of severe hypouricemia. Conclusions Our findings indicate that iRHUC is a rare disorder but that it should also be considered in patients with EIAKI, especially in those patients who manifest with moderately elevated or normal serum concentrations of uric acid during the acute phase of AKI. Mutational screening of the SLC2A9 gene is necessary for the diagnosis of iRHUC, and homozygous mutations of the SLC2A9 alleles can cause severe hypouricemia. Careful attention should be paid to any signs of hypouricemia during the recovery phase of AKI and long-term follow-up.
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Affiliation(s)
| | | | | | - Jianhua Mao
- Department of Nephrology, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China.
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Sakurai H. Transporter-centric view of urate metabolism: From genome-wide association study to pathophysiology. JOURNAL OF PHYSICAL FITNESS AND SPORTS MEDICINE 2012. [DOI: 10.7600/jpfsm.1.413] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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27
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Ochi A, Takei T, Ichikawa A, Kojima C, Moriyama T, Itabashi M, Mochizuki T, Taniguchi A, Nitta K. A case of acute renal failure after exercise with renal hypouricemia demonstrated compound heterozygous mutations of uric acid transporter 1. Clin Exp Nephrol 2011; 16:316-9. [DOI: 10.1007/s10157-011-0557-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Accepted: 10/17/2011] [Indexed: 10/16/2022]
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Ouellet G, Lin SH, Nolin L, Bonnardeaux A. [Hereditary renal hypouricemia in a Caucasian patient: a case report and review of the literature]. Nephrol Ther 2009; 5:568-71. [PMID: 19464979 DOI: 10.1016/j.nephro.2009.03.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2008] [Revised: 03/18/2009] [Accepted: 03/18/2009] [Indexed: 11/25/2022]
Abstract
Hereditary renal hypouricemia is characterized by a decreased serum uric acid, a uric acid fractional excretion above normal and the absence of another cause of hyperuricosuric hypouricemia. This pathology, generally caused by a mutation of urate renal transporter URAT1, is relatively common in Asia, but occurs very infrequently in Caucasian populations. The disease's association with exercise-induced acute renal failure is well known. This article reports the case of a 47-year-old man of Italian origin who was diagnosed with hereditary renal hypouricemia after an episode of exercise-induced acute renal failure. Molecular analysis of SLC22A12 encoding URAT1 for renal hypouricemia using peripheral blood genomic DNA of the patient was performed. Single-strand conformation polymorphism screening, amplification, and direct sequencing of SLC22A12 revealed no mutation in this patient. This suggests that another gene can be involved in this disease.
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Affiliation(s)
- Georges Ouellet
- Service de néphrologie, hôpital Maisonneuve-Rosemont, Montréal, Québec H1T 2M4, Canada
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Lam CW, Kong AP, Tsui TK, Ozaki R, Chan HM, Tong SF, Siu TS, Tam S, Chan JC. A novel mutation of SLC22A12 gene causing primary renal hypouricemia in a patient with metabolic syndrome. Clin Chim Acta 2008; 398:157-8. [DOI: 10.1016/j.cca.2008.08.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2008] [Revised: 08/01/2008] [Accepted: 08/01/2008] [Indexed: 11/25/2022]
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Jungers P, Joly D, Blanchard A, Courbebaisse M, Knebelmann B, Daudon M. [Inherited monogenic kidney stone diseases: recent diagnostic and therapeutic advances]. Nephrol Ther 2008; 4:231-55. [PMID: 18499551 DOI: 10.1016/j.nephro.2007.12.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2007] [Accepted: 12/20/2007] [Indexed: 11/24/2022]
Abstract
Hereditary monogenic kidney stone diseases are rare diseases, since they account for nearly 2% of nephrolithiasis cases in adults and 10% in children. Most of them are severe, because they frequently are associated with nephrocalcinosis and lead to progressive impairment of renal function unless an early and appropriate etiologic treatment is instituted. Unfortunately, treatment is often lacking or started too late since they are often misdiagnosed or overlooked. The present review reports the genotypic and phenotypic characteristics of monogenic nephrolithiases, with special emphasis on the recent advances in the field of diagnosis and therapeutics. Monogenic stone diseases will be classified into three groups according to their mechanism: (1) inborn errors of the metabolism of oxalate (primary hyperoxalurias), uric acid (hereditary hyperuricemias) or other purines (2,8-dihydroxyadeninuria), which, in addition to stone formation, result in crystal deposition in the renal parenchyma; (2) congenital tubulopathies affecting the convoluted proximal tubule (such as Dent's disease, Lowe syndrome or hypophosphatemic rickets), the thick ascending limb of Henlé's loop (such as familial hypomagnesemia and Bartter's syndromes) or the distal past of the nephron (congenital distal tubular acidosis with or without hearing loss), which are frequently associated with nephrocalcinosis, phosphatic stones and extensive tubulointerstitial fibrosis; (3) cystinuria, an isolated defect in tubular reabsorption of cystine and dibasic aminoacids, which results only in the formation of stones but requires a cumbersome treatment. Analysis of stones appears of crucial value for the early diagnosis of these diseases, as in several of them the morphology and composition of stones is specific. In other cases, especially if nephrocalcinosis, phosphatic stones or proteinuria are present, the evaluation of blood and urine chemistry, especially with regard to calcium, phosphate and magnesium, is the key of diagnosis. Search for mutations is now increasingly performed in as much as genetic counselling is important for the detection of heterozygotes in autosomic recessive diseases and of carrier women in X-linked diseases. In conclusion, better awareness to the rare monogenic forms of nephrolithiasis and/or nephrocalcinosis should allow early diagnosis and treatment which are needed to prevent or substantially delay progression of end-stage renal disease. Analysis of every first stone both in children and in adults should never be neglected, in order to early detect unusual forms of nephrolithiasis requiring laboratory evaluation and deep etiologic treatment.
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Affiliation(s)
- Paul Jungers
- Service de Néphrologie, Hôpital Necker, AP-HP, Paris Cedex, France
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31
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Ichida K, Hosoyamada M, Kamatani N, Kamitsuji S, Hisatome I, Shibasaki T, Hosoya T. Age and origin of the G774A mutation in SLC22A12 causing renal hypouricemia in Japanese. Clin Genet 2008; 74:243-51. [PMID: 18492088 DOI: 10.1111/j.1399-0004.2008.01021.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Renal hypouricemia is an inherited disorder characterized by impaired tubular uric acid transport. Impairment of the function of URAT1, the main transporter for the reabsorption of uric acid at the apical membrane of the renal tubules, causes renal hypouricemia. The G774A mutation in the SLC22A12 gene encoding URAT1 predominates in Japanese renal hypouricemia. From data on linkage disequilibrium between the G774 locus and the 13 markers flanking it (12 single nucleotide polymorphisms and 1 dinucleotide insertion/deletion locus), we here estimate the age of this mutation at approximately 6820 years [95% confidence interval (CI) 1860-11,760 years; median = 2460 years]. This indicates that the origin of the G774A mutation dates back from between the time when the Jomon people predominated in Japan and the time when the Yayoi people started to migrate to Japan from the Korean peninsula. These data are consistent with a recent finding that this G774A mutation was also predominant in Koreans with hypouricemia and indicate that the mutation originated on the Asian continent. Thus, this mutation found in Japanese patients was originally brought by immigrant(s) from the continent and thereafter expanded in the Japanese population either by founder effects or by genetic drift (or both).
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Affiliation(s)
- K Ichida
- Department of Pathophysiology, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan.
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Bibi G, Green Y, Nagler RM. Compositional and oxidative analysis in the saliva and serum of predialysis chronic kidney disease patients and end-stage renal failure patients on peritoneal dialysis. Ther Apher Dial 2008; 12:164-70. [PMID: 18387167 DOI: 10.1111/j.1744-9987.2008.00564.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Chronic renal failure (CRF) is often treated with peritoneal dialysis, although increased oxidative stress has been reported in such patients. The purpose of the current study was to analyze and compare oxidative stress and other compositional parameters in the saliva, serum and peritoneal dialytic fluid (PDF) of patients with chronic kidney disease (CKD), including predialysis CKD patients and end-stage renal disease (ESRD) patients treated with peritoneal dialysis. Twenty-three consenting patients participated in the current study. Saliva and serum samples collected from both groups and PDF from the dialysis patients were all examined for uric acid (UA), total antioxidant status, total protein and total albumin. The antioxidant enzyme peroxidase was examined both in saliva and serum, while the antioxidant enzyme superoxide dismutase (SOD) was examined solely in saliva. Various electrolytes were examined. Discrepancies were found between saliva and serum antioxidant status following peritoneal dialysis in ESRD patients. Oxidative stress was enhanced in the saliva but reduced in the serum. Significant changes in both oxidative-related and non-related parameters were demonstrated in saliva, serum and PDF. Salivary lactate dehydrogenase was substantially lower in the dialysis patients (by 92%, P = 0.02), as was the salivary UA concentration (by 22%, P = 0.05) and serum UA concentration (by 20%, P = 0.03). In contrast, salivary peroxidase and SOD were higher by 15% and 35%, respectively (P = 0.01), in these patients. We suggest monitoring salivary UA for assessing the baseline oral oxidative status of CRF and dialyzed patients.
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Affiliation(s)
- Guy Bibi
- Rambam Medical Center and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Pela I, Donati MA, Procopio E, Fiorini P. Lesch-Nyhan syndrome presenting with acute renal failure in a 3-day-old newborn. Pediatr Nephrol 2008; 23:155-8. [PMID: 17701224 DOI: 10.1007/s00467-007-0588-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2007] [Revised: 07/10/2007] [Accepted: 07/12/2007] [Indexed: 11/30/2022]
Abstract
Acute renal failure developed during the first 3 days after birth in a newborn subsequently diagnosed with hypoxanthine-guanine-phosphoribosyl-transferase (HPRT) deficiency. Fluid infusion and allopurinol therapy normalised renal function and serum uric acid levels. Only a few cases of acute renal failure due to acute hyperuricemic nephropathy related to HPRT deficiency have previously been reported in infants, and there are no reported cases in newborns as young as 3 days old.
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Affiliation(s)
- Ivana Pela
- Department of Paediatrics, University of Florence, Azienda Meyer, Florence, Italy.
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Abstract
Uric acid nephrolithiasis may be the final manifestation of various pathophysiological processes. Recent advances in renal urate transport have elucidated mechanisms by which hyperuricosuria occurs. However, in most uric acid stone formers the primary pathophysiologic defect is an excessively acidic urine pH rather than hyperuricosuria. Insulin resistance may contribute to the development of acidic urine by augmenting endogenous acid production and decreasing renal ammonium excretion. Medical management strategies focus primarily on alkali treatment or decreasing hyperuricosuria.
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Affiliation(s)
- Mary Ann Cameron
- The Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8885, USA.
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Nakamura A, Niimi R, Yanagawa Y. Renal hypouricemia in school-aged children: screening of serum uric acid level before physical training. Pediatr Nephrol 2006; 21:1898-900. [PMID: 16955280 DOI: 10.1007/s00467-006-0255-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2006] [Revised: 06/07/2006] [Accepted: 06/07/2006] [Indexed: 11/28/2022]
Abstract
We present two cases of a 12-year-old Japanese boy and a 14-year-old Japanese girl who had exercise-induced acute renal failure (ARF). They experienced general fatigue, nausea/vomiting, and vague discomfort in the abdomen after physical exercise at school. In case of the boy, abdominal pain subsided, but renal dysfunction lasted 17 days, with peak levels of creatinine 9.4 mg/dl and uric acid 11.3 mg/dl. On the other hand, as the girl had suffered from hypouricemia before, she followed a doctor's guidance on prevention of ARF. Consequently, she was promptly diagnosed as having exercise-induced ARF associated with hypouricemia, and rapidly recovered from ARF within a week. The difference between their clinical courses suggested a possibility that previous laboratory evaluation of serum uric acid assisted in the management of exercise-induced ARF associated with hypouricemia. School-aged children, especially Japanese and Asian, may be advised to have their serum uric acid measured before starting physical training at school.
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Affiliation(s)
- Akio Nakamura
- Department of Paediatrics, Teikyo University School of Medicine, 2-11-1 Kaga, Tokyo 173, Japan.
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Attilakos A, Voudris KA, Garoufi A, Mastroyianni S, Dimou S, Prassouli A, Katsarou E. Effect of sodium valproate monotherapy on serum uric acid concentrations in ambulatory epileptic children: a prospective long-term study. Eur J Paediatr Neurol 2006; 10:237-40. [PMID: 17035050 DOI: 10.1016/j.ejpn.2006.09.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2006] [Revised: 09/06/2006] [Accepted: 09/11/2006] [Indexed: 02/04/2023]
Abstract
PURPOSE Hyperuricemia has been shown to be related to cardiovascular morbidity and mortality. There is controversial data about the effect of sodium valproate (VPA) monotherapy on serum uric acid concentrations. The purpose of this study was to investigate by a long-term, prospective method, whether treatment with VPA monotherapy may alter serum uric acid concentrations and liver function tests in ambulatory epileptic children. MATERIAL AND METHODS Serum uric acid concentrations were determined in 28 ambulatory epileptic children before and at 6, 12 and 24 months of VPA monotherapy. Serum concentrations of biochemical markers of liver and renal function, such as alanine aminotransferase (ALT), aspartate aminotransferase (AST), lactate dehydrogenase (LDH), gamma-glutamyltransferase (gamma-GT) and creatinine (Cr) were also measured before and at 6, 12 and 24 months of VPA monotherapy. Serum VPA concentrations remained within the therapeutic range (50-100 mg/L) during the period of study. RESULTS No statistically significant changes in serum uric acid concentrations were found at 6, 12 or 24 months of treatment. Serum ALT concentrations were significantly increased at 6 and 12 months of treatment, AST concentrations at 6 and 12 months of treatment and LDH concentrations at 12 months of treatment. CONCLUSIONS VPA monotherapy does not have a significant effect on serum uric acid concentrations in ambulatory epileptic children. Further studies are needed to definitively address whether it would be useful for physicians to routinely check for elevated serum uric acid levels in children treated with VPA.
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Affiliation(s)
- Achilleas Attilakos
- Second Department of Pediatrics, University of Athens, P&A Kyriakou Children's Hospital, Athens, Greece.
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Yamamoto I, Yamamoto H, Ichida K, Mitome J, Tanno Y, Katoh N, Yokoyama K, Hosoya T. Successful living-related kidney transplantation in hereditary renal hypouricaemia. Nephrol Dial Transplant 2006; 21:2041. [PMID: 16449280 DOI: 10.1093/ndt/gfk103] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Enomoto A, Endou H. Roles of organic anion transporters (OATs) and a urate transporter (URAT1) in the pathophysiology of human disease. Clin Exp Nephrol 2005; 9:195-205. [PMID: 16189627 DOI: 10.1007/s10157-005-0368-5] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2004] [Accepted: 05/13/2005] [Indexed: 12/22/2022]
Abstract
Renal proximal and distal tubules are highly polarized epithelial cells that carry out the specialized directional transport of various solutes. This renal function, which is essential for homeostasis in the body, is achieved through the close pairing of apical and basolateral carriers expressed in the renal epithelial cells. The family of organic anion transporters (OATs), which belong to the major facilitator superfamily (SLC22A), are expressed in the renal epithelial cells to regulate the excretion and reabsorption of endogenous and exogenous organic anions. We now understand that these OATs are crucial components in the renal handling of drugs and their metabolites, and they are implicated in various clinically important drug interactions, and their adverse reactions. In recent years, the molecular entities of these transporters have been identified, and their function and regulatory mechanisms have been partially clarified. Workers in this field have identified URAT1 (urate transporter 1), a novel member of the OAT family that displays unique and selective substrate specificity compared with other multispecific OATs. In the OAT family, URAT1 is the main transporster responsible for human genetic diseases. In this review, we introduce and discuss some novel aspects of OATs, with special emphasis on URAT1, in the context of their biological significance, functional regulation, and roles in human disease.
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Affiliation(s)
- Atsushi Enomoto
- Department of Pharmacology and Toxicology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
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Stathis CG, Carey MF, Snow RJ. The influence of allopurinol on urinary purine loss after repeated sprint exercise in man. Metabolism 2005; 54:1269-75. [PMID: 16154423 DOI: 10.1016/j.metabol.2005.02.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2004] [Accepted: 02/23/2005] [Indexed: 11/24/2022]
Abstract
The influence of allopurinol on urinary purine loss was examined in 7 active male subjects (age 24.9 +/- 3.0 years, weight 82.8 +/- 8.3 kg, V O2peak 48.1 +/- 6.9 mL.kg(-1).min(-1)). These subjects performed, in random order, a trial with 5 days of prior ingestion of a placebo or allopurinol. Each trial consisted of eight 10-second sprints on an air-braked cycle ergometer and was separated by at least a week. A rest period of 50 seconds separated each repeated sprint. Forearm venous plasma inosine, hypoxanthine (Hx) and uric acid concentrations were measured at rest and during 120 minutes of recovery from exercise. Urinary inosine, Hx, xanthine, and uric acid excretion were also measured before and for 24 hours after exercise. During the first 120 minutes of recovery, plasma Hx concentrations, as well as the urinary Hx and xanthine excretion rates, were higher (P < .05) with allopurinol compared with the placebo trial. In contrast, plasma uric acid concentration and urinary uric acid excretion rates were lower (P < .05) with allopurinol. The total urinary excretion of purines (inosine + Hx + xanthine + uric acid) above basal levels was higher in the allopurinol trial compared with placebo. These results indicate that the total urinary purine excretion after intermittent sprint exercise was enhanced with allopurinol treatment. Furthermore, the composition of urinary purines was markedly affected by this drug.
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Affiliation(s)
- Christos G Stathis
- Exercise Metabolism Unit, Centre for Ageing, Rehabilitation and Exercise and Sport, Victoria University, Footscray 3011 Victoria, Australia
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Cheong HI, Kang JH, Lee JH, Ha IS, Kim S, Komoda F, Sekine T, Igarashi T, Choi Y. Mutational analysis of idiopathic renal hypouricemia in Korea. Pediatr Nephrol 2005; 20:886-90. [PMID: 15912381 DOI: 10.1007/s00467-005-1863-3] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2004] [Revised: 01/03/2005] [Accepted: 01/05/2005] [Indexed: 02/04/2023]
Abstract
Idiopathic renal hypouricemia is a hereditary disease characterized by abnormally high renal uric acid clearance. Most patients are clinically silent, but acute renal failure (ARF), urolithiasis, or hematuria may develop. A defect in the SLC22A12 gene, which encodes the renal uric acid transporter, URAT1, is the known major cause of this disorder. We performed a mutational analysis of the SLC22A12 gene in five Korean patients with idiopathic renal hypouricemia in this study. Two patients presented with microscopic hematuria, one with uric acid urolithiasis, and one with exercise-induced ARF. One patient was asymptomatic. Three different mutations, W258X, R90H and R477H, were detected in four of the patients. However, no mutation was found in the fifth ARF patient. This is the first study of SLC22A12 mutations in a country other than Japan. W258X was found to be the predominant SLC22A12 mutation in Korean renal hypouricemia patients, as has been reported in Japan.
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Affiliation(s)
- Hae Il Cheong
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea.
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Abstract
Urate is the major inert end product of purine degradation in higher primates in contrast to most other mammals because of the genetic silencing of hepatic oxidative enzyme uricase. The kidney plays a dominant role in urate elimination. The kidney excretes 70% of the daily urate production. Therefore, it is important to understand renal urate handling mechanism because the under excretion of urate has been implicated in the development of hyperuricemia that leads to gout. The urate transport systems exist in the proximal tubule but they are complicated because of their bidirectional transport and the species differences. Recently, we have identified the urate-anion exchanger URAT1 (SLC22A12) in the human kidney and found that defects in SLC22A12 lead to idiopathic renal hypouricemia. URAT1 is targeted by uricosuric and antiuricosuric agents that affect urate excretion. Molecular identification of urate transporting proteins will lead to the new drug development for hyperuricemia.
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Affiliation(s)
- Naohiko Anzai
- Department of Pharmacology and Toxicology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-shi, Tokyo 181-8611, Japan.
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Ohta T, Sakano T, Igarashi T, Itami N, Ogawa T. Exercise-induced acute renal failure associated with renal hypouricaemia: results of a questionnaire-based survey in Japan. Nephrol Dial Transplant 2004; 19:1447-53. [PMID: 15150354 DOI: 10.1093/ndt/gfh094] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND A retrospective investigation was conducted to define the clinical features of exercise-induced acute renal failure (ARF) associated with renal hypouricaemia with the aim of clarifying further the clinical features of the disease entity. METHODS A questionnaire was mailed to 43 institutions in Japan that had experienced case(s) of exercise-induced ARF associated with renal hypouricaemia. Fifty-four patients (48 males and six females) were identified from 38 institutions. RESULTS Median age at the first episode of ARF was 17 years (range 11-46). The maximal serum uric acid and creatinine levels were 4.40+/-2.49 (range 0.4-13.3) and 5.45+/-3.33 mg/dl (range 1.10-17.7), respectively. The serum uric acid level after recovery was 0.70+/-0.25 mg/dl (range 0.1-1.4). The short-term prognosis seemed to be good and histological findings in 28 patients showed minimal change or acute tubular necrosis except for one patient with chronic lesions. ARF episodes occurred predominantly in September, October and May, mostly after strenuous exercise such as a short-distance race. The first symptoms were nausea/vomiting in 51 episodes, loin pain in 35, abdominal pain in 22, general fatigue in 16 and low-grade fever in seven. Thirteen patients (24.1%) experienced recurrent ARF at various intervals. Univariate and multivariate analyses failed to demonstrate any risk factor of ARF recurrence, although no female patients experienced ARF recurrence. CONCLUSIONS The reason for the heterogeneity in ARF associated with renal hypouricaemia remains unknown. Further studies, especially on molecular mechanisms, are required to establish the best guidance against ARF recurrence.
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Affiliation(s)
- Toshiyuki Ohta
- Department of Pediatrics, Hiroshima Prefectural Hospital, 1-5-54 Ujinakanda, Minami-ku, Hiroshima 734-8530, Japan.
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Abstract
DEFINITION OF HYPOURICEMIA: Hypouricemia (serum uric acid less than 120 micro mol/l) is a biological abnormality often discovered accidentally and with a low prevalence depending on its permanent or transitory nature ranging from 0.15 to 3.38%. NEW PHYSIOLOGICAL CONCEPTS OF ITS PATHOGENESIS: Recently, our knowledge of the physiopathological mechanisms of hypouricemia has been emphasized by the identification of three systems of renal and extra-renal uric acid transport: a Cl/urate (URAT1) transporter, a multispecific organic anion transporter (OAT) and a urate transporter/channel. ETIOLOGY AND COMPLICATIONS OF HYPOURICEMIA: Through questioning, drugs and toxics (allopurinol.) are generally rapidly recognized as responsible for half of the hypouricemia encountered. It can be concomitant to a known disease: severe liver disease, neoplasia, diabetes, AIDS, syndrome of inappropriate antidiuretic hormone secretion. Hypouricemia can also be isolated and justifies the measurement of uric acid clearance, the normality or reduction of which orients towards a deficiency in xanthine-oxydase, the increase in which suggests an abnormality in uric acid transport in the proximal tubule (Fanconi syndrome, primary hereditary anomaly of tubular uric acid transport). Hypouricemia does not appear to expose the patient to any danger, but the onset of nephrolithiasis or acute renal failure secondary to the combination of severe hypouricemia and oxidant stress is always possible.
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Affiliation(s)
- Lyse Bordier
- Clinique de néphrologie, Hôpital d'Instruction des Armées du Val-de-Grâce, Paris
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Tanaka M, Itoh K, Matsushita K, Matsushita K, Wakita N, Adachi M, Nonoguchi H, Kitamura K, Hosoyamada M, Endou H, Tomita K. Two male siblings with hereditary renal hypouricemia and exercise-induced ARF. Am J Kidney Dis 2004; 42:1287-92. [PMID: 14655203 DOI: 10.1053/j.ajkd.2003.08.032] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Familial renal hypouricemia with exercise-induced acute renal failure (ARF) is rare. A 45-year-old man presented with abdominal pain, vomiting, and oliguria after severe exercise. The diagnosis was ARF based on high serum creatinine (SCr) level (5.1 mg/dL [451 micromol/L]). Renal function recovered completely within 2 weeks of conservative treatment (creatinine clearance [Ccr], 100.4 mL/min [1.67 mL/s]). After remission, laboratory results showed serum urate (SUA) of 0.8 mg/dL (48 micromol/L), and fractional excretion of uric acid (FE(UA)) of 46%. The final diagnosis was ARF associated with idiopathic renal hypouricemia. Other diseases that could increase the excretion of urate were excluded. Because only mild responses were observed both in pyradinamide and benzbromarone loading tests, he was considered to be a presecretory reabsorption disorder type. The younger brother (42 years old) also had episodes of low and middle back pain after severe exercise and experienced similar attacks at least 5 times since the age of 29. SCr level was elevated in every attack. Hypouricemia (SUA, 1.0 mg/dL [59 micromol/L]) and high urinary urate excretion (FE(UA), 65.7%) also were detected. Renal function recovered almost completely without any specific treatment. Radiologic examination of the 2 cases showed bilateral urolithiasis probably caused by the high urinary urate excretion. Sequence analysis of a urate anion exchanger known to regulate blood urate level (URAT1 gene) in both brothers showed homozygous mutation in exon 4 (W258Stop), resulting in a premature truncated URAT1 protein. Both their parents and their children showed heterozygous mutation of the URAT1 gene. This is the first report of the 2 male siblings of familial renal hypouricemia complicated with exercise-induced ARF, with definite demonstration of genetic abnormality in the responsible gene (URAT1).
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Affiliation(s)
- Motoko Tanaka
- Department of Nephrology, Akebono Clinic, Kumamoto, Japan.
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Ito O, Hasegawa Y, Sato K, Mitsui H, Yuda F, Sato H, Ito S, Kudo KI. A case of exercise-induced acute renal failure in a patient with idiopathic renal hypouricemia developed during antihypertensive therapy with losartan and trichlormethiazide. Hypertens Res 2003; 26:509-13. [PMID: 12862209 DOI: 10.1291/hypres.26.509] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Exercise-induced acute renal failure (ARF) developed in a 45-year-old man during antihypertensive therapy with losartan and trichlormethiazide. The antihypertensive therapy was stopped and marked hypouricemia became apparent during improvement of his renal function. The daily urinary excretion of uric acid was normal and an increased fractional excretion of uric acid was observed. Renal biopsy revealed that the kidney was recovering from acute tubular necrosis with interstitial fibrosis. Based on the results of pyrazinamide and benzbromarone tests, we classified this case as one of presecretory reabsorption defect of uric acid. Antihypertesive therapy with benidipine and candesartan was initiated, and the patient has not had any ARF episodes since. Because idiopathic renal hypouricemia can be associated with exercise-induced ARF and chronic renal dysfunction, careful antihypertensive therapy and follow-up evaluation of renal function might be necessary for hypertensive patients with idiopathic renal hypouricemia.
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Affiliation(s)
- Osamu Ito
- Department of Internal Medicine, Yamagata City Hospital Saiseikan, Yamagata, Japan.
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Kramer BK, Muller R, Kammerl MC, Barner C, Stubanus M, Lackner KJ, Fischereder M. Effects of fluid intake on urinary protein excretion and haematuria during and after a 25-km march. Nephrology (Carlton) 2002. [DOI: 10.1046/j.1440-1797.2002.00106.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Kurihara I, Soma J, Sato H, Ikarashi T, Tsunoda K, Miura R, Suzuki T, Sato M, Furuyama T, Ito S, Saito T. A case of exercise-induced acute renal failure in a patient with enhanced renal hypouricaemia. Nephrol Dial Transplant 2000; 15:104-6. [PMID: 10607777 DOI: 10.1093/ndt/15.1.104] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- I Kurihara
- First Department of Internal Medicine, Sendai Teishin Hospital, Second Department of Internal Medicine and Department of Blood Purification, Tohoku University School of Medicine, Sendai, Japan
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Sato T, Kuno T, Tashiro K, Fujita I, Miyazaki S. Exercise-induced acute renal failure in a girl with renal hypouricemia. ACTA PAEDIATRICA JAPONICA : OVERSEAS EDITION 1998; 40:93-5. [PMID: 9583212 DOI: 10.1111/j.1442-200x.1998.tb01413.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A 10-year-old Japanese girl developed acute renal failure following a 100-meter dash during physical training at school. After the run, she experienced intense pain in the loins with nausea and vomiting lasting more than 12 h. On the following morning, she was found to have mild proteinuria and acute renal failure (ARF). Serum creatinine and blood urea nitrogen were elevated, but the serum uric acid level was normal (3.1 mg/dL). With recovery of renal function over the ensuing days, hypouricemia (0.6 mg/dL) became evident in the patient. Although the pathophysiological association between renal hypouricemia and ARF is not known, oxygen free radicals have been implicated in the pathogenesis for ischemic-reperfusion ARF. Superoxide production by neutrophils stimulated by N-formyl methionine leucyl-phenylalanine was normal in the patient both before and following exercise. Pyrazinamide and probenecid tests were undertaken on both the patient and her parents, who had borderline hypouricemia, to determine their renal tubular handling of uric acid. Results showed that the patient and her mother had a subtotal reabsorption defect, while the father had defective postsecretory uric acid reabsorption.
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Affiliation(s)
- T Sato
- Department of Pediatrics, Saga Medical School, Nabeshima, Japan.
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Ninomiya M, Ito Y, Nishi A, Matsumoto T, Koga A, Hori Y, Nishida H, Nomura G, Kato H. Recurrent exercise-induced acute renal failure in renal hypouricemia. Acta Paediatr 1996; 85:1009-11. [PMID: 8863890 DOI: 10.1111/j.1651-2227.1996.tb14206.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
We describe a male patient with four episodes of acute renal failure after strenuous exercise occurring between the age of 14 and 25 years. He was found to have low serum uric acid (0.4 mg dl-1 after recovery) and high fractional excretion of uric acid. A benzbromarone/pyrazinamide test suggested that renal hypouricemia was due to defective proximal tubular reabsorption of uric acid at a presecretory site. A renal biopsy revealed acute tubular necrosis, a renal computer tomography scan showed patchy contrast enhancement and a treadmill exercise test induced an immediate fall in creatinine clearance. These findings suggest that the cause of acute renal failure was renal vasoconstriction rather than obstruction by uric acid crystals.
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Affiliation(s)
- M Ninomiya
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Japan
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