Hyperuricemia is independently associated with coronary heart disease and renal dysfunction in patients with type 2 diabetes mellitus

Prevalence of Hyperuricemia and Associated Factors Among Patients With Type 2 Diabetes Mellitus in Northwestern Tanzania: A Cross-Sectional Study

Background

There has been increasing evidence of the association between hyperuricemia and diabetes mellitus (DM). In the general population, hyperuricemia has been associated with pre-diabetes. In DM patients, hyperuricemia has been associated with poor outcomes.

Objectives

The objective was to determine the proportion of hyperuricemia and associated factors among patients with type 2 DM in Mwanza, Tanzania.

Design

This was a cross-sectional study.

Methods

This study was conducted from January to March 2023 among patients with type 2 DM attending clinic at Bugando Medical Centre, Mwanza. Data was obtained from a structured questionnaire. Serum uric acid, HbA1c, lipid profile, and renal functions were analyzed. Analysis was done via STATA version 17. The primary outcome was the proportion of hyperuricemia among patients with type 2 DM, and logistic regression models were used to analyze associated factors.

Results

Out of 360 patients, 59.7% were female. The median age was 61 years [IQR 57-68], and the median duration of DM was 5 years [IQR 3-9]. The mean HbA1c was 8.2 ± 2.5%, with 60% of patients having poor control. Most patients had hypertension (78.9%) and were overweight or obese (81.9%). The proportion of patients with DM and hyperuricemia was 44.4%, with mean serum uric acid levels among males and females of 410 ± 137 and 385 ± 119 µmol/L, respectively. We found that being female (P = .001), overweight (P = .021), or obese (P = .007), and having chronic kidney disease (P < .001) was associated with hyperuricemia among patients with type 2 DM.

Conclusion

The burden of hyperuricemia among type 2 DM patients is quite high, and it is associated with female gender, high body mass index, lipids, and chronic kidney disease. This calls for regular screening of hyperuricemia in the population, and more studies are needed to establish the outcomes associated with hyperuricemia and create a treatment guideline.

Immunomodulation and immunopharmacology in heart failure

The immune system is intimately involved in the pathophysiology of heart failure. However, it is currently underused as a therapeutic target in the clinical setting. Moreover, the development of novel immunomodulatory therapies and their investigation for the treatment of patients with heart failure are hampered by the fact that currently used, evidence-based treatments for heart failure exert multiple immunomodulatory effects. In this Review, we discuss current knowledge on how evidence-based treatments for heart failure affect the immune system in addition to their primary mechanism of action, both to inform practising physicians about these pleiotropic actions and to create a framework for the development and application of future immunomodulatory therapies. We also delineate which subpopulations of patients with heart failure might benefit from immunomodulatory treatments. Furthermore, we summarize completed and ongoing clinical trials that assess immunomodulatory treatments in heart failure and present several therapeutic targets that could be investigated in the future. Lastly, we provide future directions to leverage the immunomodulatory potential of existing treatments and to foster the investigation of novel immunomodulatory therapeutics.

Sodium glucose cotransporter 2 inhibitors and gout risk: a sequence symmetry analysis

OBJECTIVE

To examine the association between sodium-glucose cotransporter 2 inhibitors (SGLT2-I) and gout incidence in patients with diabetes is the objective.

METHOD

National administrative data from the United States Veterans Health Administration were used to identify patients initiated on SGLT2-I from 2012 to 2020. Sequence symmetry analysis was performed to contrast the number of patients with incident gout within the year following SGLT2-I initiation to the number within the year preceding initiation. Exposure counterfactual analyses examined the relationship between potential therapeutic alternatives to SGLT2-I and risk for gout.

RESULTS

The primary outcome of incident gout was observed in 441 patients preceding SGLT2-I initiation and 273 patients following SGTL2-I (symmetry ratio (SR) = 0.62; 95% CI: 0.53-0.72). This finding remained consistent across multiple sensitivity analyses. A reduction in gout incidence was also observed in exposure counterfactual cohorts initiating dipeptidyl peptidase-4 inhibitor (SR = 0.67; 95% CI: 0.63-0.72) and thiazolidinediones (SR = 0.72; 95% CI: 0.65-0.79), but not glucagon-like peptide-1 receptor agonist (GLP1-RA) (SR = 0.93; 95% CI: 0.77-1.12).

CONCLUSIONS

The risk for incident gout was significantly reduced following SGLT2-I initiation. GLP1-RA had minimal to no impact on gout risk. Our findings support pleiotropic benefits of SGLT2-I use in patients with diabetes at elevated risk for gout. Key points • Early studies suggest SGLT2-inhibitors may decrease risk for gout • Our sequence symmetry analysis confirmed this observation • DPP4s and thiazolidinediones were also associated with lower gout risk • SLGT2 inhibitors may be beneficial in patients with diabetes at risk for gout.

Contributing Factors of Diabetes Mellitus among Patients with Gout (Results of the Long-Term Prospective Study)

It is assumed that the risk of developing type 2 diabetes mellitus (T2DM) in patients with gout is influenced by both generally accepted risk factors and factors related to gout. The aim of the study was to evaluate the impact of various risk factors for T2DM in patients with gout. A total of 444 patients (49 women, 395 men) ≥18 years old with gout and without DM were included. The duration of observation was 5.66 [2.69; 7.64] years. To identify the factors associated with the risk of developing T2DM, multivariate logistic regression was used, which included sex; T2DM in relatives; insufficient physical activity; unbalanced diet; age  ≥ 45 years; ≥4 attacks per year; presence of tophi; BMI ≥30 kg/m2; allopurinol, febuxostat, glucocorticoids, diuretics, metformin, colchicine; GFR < 60 mL/min/1.73 m2; serum uric acid level (sUA) ≥ 420 µmol/L and  ≥ 480 µmol/L. T2DM developed in 108 (24.3%) patients. According to the multivariate model, the presence of ≥4 attacks of arthritis per year increased the risk of T2DM (OR = 5.23; 95% CI: 2.98-9.19; p = 0.0001); presence of tophi (OR = 2.61; 95% CI: 1.50-4.54; p = 0.001); sUA ≥ 480 µmol/L (OR = 2.26; 95% CI: 1.02-5.00; p = 0.144); diuretics (OR = 2.35; 95% CI: 1.19-4.64; p = 0.014). Febuxostat (OR = 0.31; 95% CI: 0.11-0.84; p = 0.022) and metformin (OR = 0.49; 95% CI: 0.21-1.16; p = 0.107) reduced the risk of developing T2DM. Risk of T2DM in patients with gout is associated with high incidence of arthritis attacks, MK ≥ 480 μmol/L, hypertension, diuretic use, and febuxostat and metformin reduces risk.

Can SGLT2 inhibitors prevent incident gout? A systematic review and meta-analysis

PURPOSE

To collate the effect of SGLT2 inhibitors (SGLT2i) on adverse gout events in people with type 2 diabetes mellitus (T2DM).

METHODS

PubMed/MEDLINE, Embase, and Web of Science databases were systematically searched using appropriate keywords/MeSH/Emtree terms till January 25, 2022, to identify observational studies, randomized controlled trials (RCTs) or post hoc analysis reporting incident gout events and/or commencement of anti-gout drug in people with T2DM receiving SGLT2i versus those not receiving SGLT2i. Subgroup analyses were performed using comparators as placebo/other antidiabetic drugs and presence/absence of baseline hyperuricemia (uric acid ≥ 7 or < 7 mg/dl). Hazard ratios (HR) with 95% confidence intervals (CI) were calculated.

RESULTS

We identified 5 studies (3 observational, 2 post hoc analysis of RCTs) pooling data retrieved from 568,010 people with T2DM. Pooled analysis showed that SGLT2i use was associated with 30% reduction in incident gout events/gout flares (HR 0.70, 95% CI: 0.59, 0.84, p < 0.001, I² = 84%). Sensitivity analysis after excluding the retrospective observational study showed similar estimates (HR 0.65, 95% CI: 0.60, 0.70, p < 0.001, I² = 0%). Subgroup analysis of data retrieved only from RCTs also showed significant benefits (HR 0.74, 95% CI: 0.55, 0.98, p = 0.03, I² = 0%). Pooled analysis of data from 2 studies showed that SGLT2i use led to a significant reduction in the need for commencement of new anti-gout drug (pooled HR 0.58, 95% CI: 0.48, 0.71, p < 0.001, I² = 0%). Consistent benefits were also observed for subgroup without baseline hyperuricemia (pooled HR 0.65, 95% CI: 0.47, 0.89, p < 0.01, I² = 0%).

CONCLUSIONS

SGLT2i may potentially prevent gout-related adverse events in people with T2DM.

The relation between serum uric acid levels and diabetic peripheral neuropathy in type 2 diabetes in Guilan, north of Iran

BACKGROUND

Diabetic peripheral neuropathy (DPN) is one of the most common chronic microvascular complications in type 2 diabetes mellitus (T2DM). Hence, the present study aimed to investigate the association between Serum Uric Acid (SUA) levels and diabetic peripheral polyneuropathy in patients with type 2 diabetes.

METHODS

We performed this case-control study during 2019-2020 on individuals with diabetes referring to the Razi clinic of Rasht, in the north of Iran. Polyneuropathy in patients was assessed based on the Neuropathy Disability Score (NDS), Diabetic neuropathy symptom score (DNS) scoring system, and electromyography (EMG)/nerve conduction velocity (NCV). The inclusion criterion for the control group was normal EMG/NCV. Then, the patients were assessed for SUA level and also laboratory results.

RESULTS

In total, 230 patients with type 2 diabetes were examined. The mean SUA level in the DPN group was significantly higher compared to the control group (6.72 ± 1.75 vs. 4.57 ± 1.49 mg/dL). With increasing the SUA, the odds of developing neuropathy increased by 2.2 times (OR = 2.2). The risk factors for diabetic polyneuropathy included gender (male) (OR = 0.347), SBP (OR = 1.1), retinopathy (OR = 3.29), and microalbuminuria (OR = 4.44). The chance of developing polyneuropathy in patients with retinopathy was 3.3 times higher than in the control group, it was 4.4 times in microalbuminuria patients.

CONCLUSION

Elevated SUA level increased the chance of developing peripheral polyneuropathy in a person with type 2 diabetes. SUA levels higher than 5.25 mg / dL expose a person with type 2 diabetes to developing peripheral polyneuropathy.

Association of Serum Total Bilirubin and Uric Acid with Low Glomerular Filtration Rate Diabetic Kidney Disease in Type 2 Diabetic Patients

BACKGROUND

Diabetic kidney disease (DKD) is one of the major complications of Type 2 diabetes, clinically characterized by a progressive increase in albuminuria and/or a subsequent decline in glomerular filtration rate. Identification of novel risk factors contributes to reduction in the risk of diabetic kidney disease. Bilirubin, as an antioxidant and anti-inflammatory molecule, is believed to have a protective role in kidney disease. On the other hand, uric acid is implicated in the pathogenesis of DKD due to its pro-oxidant and pro-inflammatory property in vascular tissues.

METHODS

A hospital based comparative cross-sectional study was conducted from October 2020 to March 2021 on 200 eligible Type 2 diabetic patients (58 with DKD and 142 without DKD) to assess the association of serum total bilirubin and serum uric acid levels with low GFR diabetic kidney disease using consecutive sampling technique.

RESULTS

The serum total bilirubin level was significantly decreased (0.15±2.29, mean±SD) in the DKD group compared to the non-DKD group (0.19±2.26), whereas the mean±SD serum uric acid was significantly increased in the DKD group (7.13±2.21) compared to the non-DKD group (5.24±1.92). A low serum total bilirubin level was significantly associated with increased risk of DKD in multivariate analysis (AOR=2.23, 95% CI=1.55-4.13) also to high serum uric acid levels (AOR=2.09, 95% CI=1.06-4.12). Moreover, a low serum total bilirubin level was significantly associated with increased risk of DKD among patients with high serum uric acid (AOR=2.55, 95% CI=1.05-6.19). Similarly, high serum uric acid was significantly associated with increased risk of DKD among patients with low serum total bilirubin (AOR=3.49, 95% CI=1.29-9.42).

CONCLUSION

Co-presence of low serum total bilirubin and high serum uric acid may be useful for stratification of DKD risk among patients with Type 2 diabetes mellitus.

Hyperuricemia prevalence and its association with metabolic disorders: a multicenter retrospective real-world study in China

Background

The prevalence of hyperuricemia (HUA) and gout continues to increase in China. Research suggests that HUA may be related to many diseases other than gout. However, further population research is required to investigate the association between HUA and metabolic syndromes. This study sought to investigate the prevalence of HUA in an average population in China, and the association between serum uric acid (UA) levels and related metabolic disorders.

Methods

This multicenter retrospective real-world study examined the hospital information system data of 4 tertiary hospitals in 3 provinces in China. The data of patients aged between 18 and 80 years, who had attended at least 1 medical appointment at which their UA level was recorded, were analyzed to evaluate associations between UA levels and metabolic disorders.

Results

Among the 374,506 enrolled subjects (49.7% male; mean age 51.5 years old), the overall prevalence of HUA and gout were 14.8% and 0.5%, respectively. The prevalence was higher among males than females (17.6% vs. 12.0%, 0.8% vs. 0.1%; both P<0.001). Groups exhibiting higher UA levels had increased adjusted odds ratios for dyslipidemia and chronic kidney disease (CKD) in both sexes. Changes in UA levels from the baseline were negatively correlated with changes in the estimated glomerular filtration rate and hemoglobin A1c among both sexes (all P<0.001), and were positively correlated with changes in total cholesterol (TC), triglyceride (TG), and low-density lipoprotein cholesterol (LDL-C) (all P<0.05) among males, and changes in TC, TG, LDL-C and glucose (all P<0.001) among females.

Conclusions

HUA is associated with dyslipidemia and CKD both cross-sectionally and longitudinally. Similar phenomena were observed in both sexes.

Serum Uric Acid Levels and Risk of Rapid Decline of Estimated Glomerular Filtration Rate in Patients with Type 2 Diabetes: Findings from a 5-Year Prospective Cohort Study

This study investigated the association between serum uric acid (SUA) levels with rapid decline of the estimated glomerular filtration rate (eGFR) in type 2 diabetes (T2 DM) patients. A prospective cohort study was conducted in a community-based hospital in Vietnam. We followed 405 T2DM patients with normal kidney function for five years. Rapid progression of kidney function was defined as an average annual decrease of eGFR of at least 4 mL/min/1.73 m² and was found in 16.0% of patients. Patients in the SUA high tertile ( ≥6 mg/dL) had higher BMI (p = 0.004), lower HbA1c (p = 0.001), lower eGFR (p < 0.001) and higher rate of hypertension than low and middle tertile. After adjusting for age and sex, rapid progression of renal function was significantly associated with SUA level (OR = 1.22, 95% CI 1.02-1.45, p = 0.026). This association was marginally significant when more covariates were included in the model (OR = 1.20, 95% CI 0.99-1.46, p = 0.065). However, the association between tertiles of SUA and rapid decline of eGFR was not statistically significant. This study demonstrates neither a strong significant association between SUA and rapid decline of eGFR nor evidence to refuse the role of SUA levels in the increased risk of renal function decline in in T2DM patients.

Dietary Acid Load Is Positively Associated with the Incidence of Hyperuricemia in Middle-Aged and Older Korean Adults: Findings from the Korean Genome and Epidemiology Study

Hyperuricemia has been associated with a number of chronic diseases, such as type 2 diabetes mellitus, hypertension, and cardiovascular diseases. Dietary acid load plays a key role in regulating uric acid levels. We hypothesized that potential renal acid load (PRAL) and net endogenous acid production (NEAP) score would be positively associated with the incidence of hyperuricemia. Data from the Health Examinees study, a part of the Korean Genome and Epidemiology Study were used. The PRAL and NEAP scores were calculated to evaluate the dietary acid load. Hyperuricemia was defined as follows: >7.0 mg/dL and >6.0 mg/dL of serum uric acid levels in men and women, respectively. Multivariable Cox proportional hazard models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the incidence of hyperuricemia. We identified 2500 new cases of hyperuricemia during a mean follow-up of 5.0 years (223,552 person years). The participants in the highest quartiles of the PRAL and NEAP score had 21% (HR: 1.21, 95% CI: 1.07–1.35, p for trend <0.0001) and 17% (HR: 1.17, 95% CI: 1.04–1.31, p for trend <0.0001) higher risks for hyperuricemia, respectively, than those in the lowest quartiles, after adjusting for covariates. In this prospective cohort study, a higher dietary acid load was positively associated with a higher incidence of hyperuricemia in Korean adults. This suggests that an alkaline diet may be an effective strategy to reduce the future risk of elevated uric acid levels.

Triterpenoid acids from medicinal mushroom Inonotus obliquus (Chaga) alleviate hyperuricemia and inflammation in hyperuricemic mice: Possible inhibitory effects on xanthine oxidase activity

The purpose of this study was to explore the hypouricemic effect in hyperuricemia mice of triterpenoid acids from Inonotus obliquus (TAIO), and decipher of the underlying xanthine oxidase inhibitory mechanism. Measurement of xanthine oxidase (XO) inhibitory activity was assayed. Organ indexes and serum biochemical indicators were measured in potassium oxonate-induced hyperuricemia mice. Studies showed that TAIO had the strong inhibitory effect on XO activity, and its inhibition type was mixed and reversible. In vivo, TAIO decreased efficiently uric acid level, hepatic XO, serum blood urea nitrogen activities in hyperuricemia mice. Indicating that TAIO may ameliorate kidney damage and relieve inflammation in hyperuricemic mice, and had the inhibitory effect on XO activity. Furthermore, eight triterpenoids were identified by Ultra performance liquid chromatography electrospray quadrupole time of flight mass spectrometry. These findings proved that triterpenoids from Inonotus obliquus would have potential biological characteristics and effect on controlling hyperuricemia and gout as an active supplement. PRACTICAL APPLICATIONS: There are a large amount of evidence indicating that hyperuricemia and gout are related to the hypertension and obesity. And gout and hyperuricemia are also possible connection with cardiovascular disease and metabolic syndrome. Currently, xanthine oxidase is the target of many kinds of chemical drugs at present, but the therapeutic drugs used in clinical medicine will produce more or less side effects. Therefore, the aim of this study was to explore the material basis of effective substances for reducing uric acid in Inonotus obliquus and to evaluate its effect. This study can provide a promising application of Inonotus obliquus in the fields of functional foods or medicines for gout and hyperuricemia.

Serum Uric Acid and Diabetes: From Pathophysiology to Cardiovascular Disease

Hyperuricemia, has been traditionally related to nephrolithiasis and gout. However, it has also been associated with the development of type 2 diabetes mellitus (T2DM) and cardiometabolic and cardiovascular diseases. Pathophysiologically, elevated serum uric acid (SUA) levels may be associated with abnormal lipid and glucose metabolism. In this narrative review, we consider the associations between hyperuricemia, hyperglycemia, atherosclerosis and thrombosis. Furthermore, we comment on the available evidence linking elevated SUA levels with the incidence and outcomes of coronary heart disease, stroke, peripheral artery disease and non-alcoholic fatty liver in subjects with T2DM. The effects of antidiabetic drugs (e.g. metformin, pioglitazone, sulfonylureas, dipeptidyl peptidase 4 inhibitors, glucagon-like peptide-1 receptor agonists, sodium-glucose cotransporter 2 inhibitors and insulin) on SUA concentrations are also reviewed.

Uric acid lowering improves insulin sensitivity and lowers blood pressure: a meta-analysis of randomized parallel-controlled clinical trials

Objectives

This meta-analysis aimed to investigate whether uric acid lowering treatment can improve β-cell function and insulin sensitivity.

Methods

PubMed, Cochrane Library, EMBASE and China Biology Medicine were searched up to March 1, 2020. Randomized controlled clinical trials of urate lowering therapy in hyperuricemia patients were included in meta-analysis. Effect size was estimated as mean difference with 95% confidence interval (CI).

Results

Our search yielded 7 eligible trials with 503 participants. This meta-analysis showed that uric acid-lowering therapy decreased fasting insulin -1.43 µIU/ml (weighted mean differences (WMD, 95% CI -2.78 to -0.09), homeostasis model assessment of insulin resistance -0.65 (WMD, 95% CI -1.05 to -0.24), systolic blood pressure -2.45 mm Hg (WMD, 95%CI -4.57 to -0.33) and diastolic blood pressure -3.41 mm Hg (WMD, 95%CI -3.87 to -2.95). However, the treatment had no significant effect on fasting plasma glucose (WMD -0.19 mmol/L, 95%CI -0.42 to 0.05), homeostasis model assessment of β-cell function index (WMD -0.02, 95%CI -0.28 to 0.24), total cholesterol (WMD 0.18 mg/dl; 95%CI, -1.39 to 1.75) and triglyceride (WMD 3.15 mg/dl, 95% CI -9.83 to 16.14).

Conclusion

Uric acid-lowering therapies might improve insulin sensitivity and lower blood pressure, but had no significant effect on HOMA-β and serum lipids.

Medicinal Plants as a Drug Alternative Source for the Antigout Therapy in Morocco

BACKGROUND

The gout is a metabolic disease that is associated with a high level of uric acid in the blood. This disease is treated with some medications that aim to reduce serum urate levels. However, the use of various medicines leads to the appearance of some side effects, hence the importance of using other treatments based on natural resources.

OBJECTIVE

This study presents some medical treatments, their side effects, and some plants that are used for gout management in Morocco in the aim to valorize them.

METHODS

We have been consulting various English publications in PubMed, Web of Science, and ScienceDirect published between 1991 and 2019 using the following keywords "drugs," "gout," "Morocco," "medicinal plants," "in vitro," and "in vivo" terms. Then, we have classified the medicines, according to their action mechanisms, and we have cited some species that were reported in Moroccan pharmacopeia as antigout.

RESULTS

Three methods of the gout medical management were cited in this work: xanthine oxidase inhibitors, uric acid excretion enhancer, and uricase recombinant. However, it was found that these treatments had various side effects. We have described 23 species, and some of them showed experimentally an antigout effect by blocking the "xanthine oxidase" enzyme. These plants belong to 11 families. Lamiaceae represents the most dominant family with six species followed by Asteraceae with two species. Colchicine isolated from Colchicum autumnale is the most known compound for its efficiency towards gout.

CONCLUSION

This work summarized different treatments particularly medicinal plants that are used in Morocco to treat gout disease by blocking uric acid secretion. However, several studies are needed to valorize these antigout natural sources.

Uric acid predicts long-term cardiovascular risk in type 2 diabetes but does not mediate the benefits of fenofibrate: The FIELD study

AIM

To explore the relationship between baseline uric acid (UA) levels and long-term cardiovascular events in adults with type 2 diabetes (T2D) and to determine whether the cardioprotective effects of fenofibrate are partly mediated through its UA-lowering effects.

METHODS

Data from the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) trial were utilized, comprising 9795 adults with T2D randomly allocated to treatment with fenofibrate or matching placebo. Plasma UA was measured before and after a 6-week, active fenofibrate run-in phase in all participants. Cox proportional hazards models were used to explore the relationships between baseline UA, pre-to-post run-in reductions in UA and long-term cardiovascular outcomes.

RESULTS

Mean baseline plasma UA was 0.33 mmol/L (SD 0.08). Baseline UA was a significant predictor of long-term cardiovascular events, with every 0.1 mmol/L higher UA conferring a 21% increase in event rate (HR 1.21, 95% CI 1.13-1.29, P < .001). This remained significant after adjustment for treatment allocation, cardiovascular risk factors and renal function. The extent of UA reduction during fenofibrate run-in was also a significant predictor of long-term cardiovascular events, with every 0.1 mmol/L greater reduction conferring a 14% lower long-term risk (HR 0.86, 95% CI 0.76-0.97, P = .015). This effect was not modified by treatment allocation (P_interaction = .77).

CONCLUSIONS

UA is a strong independent predictor of long-term cardiovascular risk in adults with T2D. Although greater reduction in UA on fenofibrate is predictive of lower cardiovascular risk, this does not appear to mediate the cardioprotective effects of fenofibrate.

[Advantages of therapy with sodium glucose cotransporter type 2 inhibitors in patients with type 2 diabetes mellitus in combination with hyperuricemia and gout]

Currently, only two drugs for reducing uric acid (UA), allopurinol and febuxostat, are registered in the Russian Federation, but their use does not allow to achieve the target level of UA in all cases. According to the results of numerous randomized trials, hyperuricemia and gout are associated with the corresponding components of the metabolic syndrome, including diabetes mellitus. The influence of factors is due to the need to search for new drugs that have a complex effect on several components of metabolic syndrome at once. Potentially attractive in this regard is a new group of drugs for the treatment of type 2 diabetes mellitus inhibitors of the sodium-glucose cotransporter of type 2, which, in addition to the main hypoglycemic actions, showed positive effects on the cardiovascular system, kidneys, as well as lowering UA.

Asymptomatic hyperuricemia and incident congestive heart failure in elderly patients without comorbidities

BACKGROUND AND AIMS

Although hyperuricemia is associated with congestive heart failure (CHF), hyperuricemic patients frequently have other comorbidities. Thus, it is difficult to distinguish the role of hyperuricemia from that of other comorbid conditions in CHF. The aim of this study was to evaluate the association between hyperuricemia and CHF in elderly patients without comorbidities.

METHODS AND RESULTS

Subjects aged ≥65 years were analyzed at enrollment (2009-2012) and during the 4-year follow-up period at the Kangjian Community Health Center of Shanghai. Subjects were excluded if they had hypertension, diabetes mellitus, preexisting cardiovascular disease, hyperlipidemia, overweight or obesity, a history of gout or hyperuricemia and were taking medication for their condition, or chronic kidney disease. The primary outcome of this study was to investigate the impact of asymptomatic hyperuricemia on incident CHF. We used Cox regression to estimate the hazard ratio (HR) for incident CHF events between hyperuricemic (defined as an SUA level >7 mg/dL in men and ≥6 mg/dL in women) and normouricemic subjects. A total of 2749 subjects (70.9 ± 6.0 years) were followed for 47.4 ± 3.6 months. Asymptomatic hyperuricemia was associated with an increased cumulative incidence of incident CHF events (6.5% versus 3.1%, odds ratio [OR] = 2.15, 95% confidence index [CI]: 1.39-3.33, p = 0.001). After adjusting for confounding factors, including baseline eGFR, hyperuricemia independently predicted the risk of incident CHF events (HR = 2.34, 95% CI: 1.50-3.63, p < 0.001).

CONCLUSION

Asymptomatic hyperuricemia was a valuable biomarker for predicting the development of incident CHF in elderly patients without comorbidities.

Association of gout with CAD and effect of antigout therapy on CVD risk among gout patients

Hyperuricemia has been identified as an independent risk factor for coronary artery disease (CAD), with a dose-response association. In this study, we explored the causal association between gout and antigout medication and the risk of incidental CAD. We sampled data from the National Health Insurance Research Database and recruited 37,091 patients as the gout cohort, and 37,091 controls. Our primary endpoint was the diagnosis of CAD during follow-up. The overall study population was followed up until CAD diagnosis, withdrawal from the National Health Insurance program, or the end of the study. Cox proportional hazards regression models were used to examine the effect of gout on the risk of CAD, represented by the HR with the 95% CI. Patients with gout were at greater risk of CAD, compared with those without gout: HR=1.49 after adjusting for potential confounders. Non-steroidal anti-inflammatory drugs and prednisolone use was associated with a reduced risk of CAD: HR=0.63 and 0.50, respectively. Patients with gout, treated with antigout medication, exhibited a reduced risk of CAD compared with non-gout patients. Among patients with gout, those on antigout therapy had 32% lower risk compared with those not on antigout therapy: adjusted HR=0.68, 95% CI 0.63 to 0.73. Gout increases the risk of CAD, and the use of antigout medication reduces CAD risk. These results indicate that gout or hyperuricemia is a modifiable risk factor for CAD.

Nomogram Based on Risk Factors for Type 2 Diabetes Mellitus Patients with Coronary Heart Disease

INTRODUCTION

This study aimed to study risk factors for coronary heart disease (CHD) in type 2 diabetes mellitus (T2DM) patients and establish a clinical prediction model.

RESEARCH DESIGN AND METHODS

A total of 3402 T2DM patients were diagnosed by clinical doctors and recorded in the electronic medical record system (EMRS) of six Community Health Center Hospitals from 2015 to 2017, including the communities of Huamu, Jinyang, Yinhang, Siping, Sanlin and Daqiao. From September 2018 to September 2019, 3361 patients (41 patients were missing) were investigated using a questionnaire, physical examination, and biochemical index test. After excluding the uncompleted data, 3214 participants were included in the study and randomly divided into a training set (n = 2252) and a validation set (n = 962) at a ratio of 3:1. Through lead absolute shrinkage and selection operator (LASSO) regression analysis and logistic regression analysis of the training set, risk factors were determined and included in a nomogram. The C-index, receiver operating characteristic (ROC) curve, calibration plot and decision curve analysis (DCA) were used to validate the distinction, calibration and clinical practicality of the model.

RESULTS

Age, T2DM duration, hypertension (HTN), hyperuricaemia (HUA), body mass index (BMI), glycosylated haemoglobin A1c (HbA1c), high-density lipoprotein (HDL-C) and low-density lipoprotein (LDL-C) were significant factors in this study. The C-index was 0.750 (0.724-0.776) based on the training set and 0.767 (0.726-0.808) based on the validation set. Through ROC analysis, the set area was 0.750 for the training set and 0.755 for the validation set. The calibration test indicated that the S:P of the prediction model was 0.982 in the training set and 0.499 in the validation set. The decision curve analysis showed that the threshold probability of the model was 16-69% in the training set and 16-73% in the validation set.

CONCLUSION

Based on community surveys and data analysis, a prediction model of CHD in T2DM patients was established.

Empagliflozin Attenuates Hyperuricemia by Upregulation of ABCG2 via AMPK/AKT/CREB Signaling Pathway in Type 2 Diabetic Mice

Hyperuricemia (HUA) is a metabolic disease characterized by elevated serum uric acid (SUA). Empagliflozin, a kind of sodium-glucose cotransporter 2 inhibitors, has recently emerged as a new antidiabetic agent by facilitating glucose excretion in urine. Moreover, there was evidence of SUA reduction following treatment with empagliflozin in addition to glycaemic control, while the molecular mechanisms remain unknown. To investigate the potential mechanisms, the model of type 2 diabetes (T2DM) with HUA was established by combination of peritoneal injection of potassium oxonate and intragastric administration of hypoxanthine in KK-Ay mice. A series of method such as RT-PCR, western blot, immunochemistry, immunofluorescence were conducted to explore the mechanism. Our results showed that empagliflozin significantly ameliorated the levels of SUA and blood glucose in T2DM mice with HUA. Furthermore, in both kidney and ileum, empagliflozin obviously promoted protein expression of uric acid (UA) transporter ABCG2, p-AMPK, p-AKT and p-CREB. The same trend was observed in human tubular epithelial (HK-2) cells. Additionally, through application of an AMPK inhibitor (Compound C), it was further confirmed empagliflozin exerted its anti-hyperuricemic effects in an AMPK dependent manner. Meanwhile, with the help of ChIP assay and luciferase reporter gene assay, we found that CREB further activated ABCG2 via binding to the promoter of ABCG2 to induce transcription. Taken together, our study demonstrated that empagliflozin treatment played an essential role in attenuating HUA by upregulation of ABCG2 via AMPK/AKT/CREB signaling pathway.

The association between uric acid levels and renal function of CKD patients with hyperlipidemia: a sub-analysis of the ASUCA trial

Background

The influence of uric acid (UA) on renal function and the significance of UA-lowering therapy are unclear. The purpose of the sub-analysis of the Assessment of Clinical Usefulness in chronic kidney disease patients with Atorvastatin (ASUCA) trial was to evaluate the influence of serum UA levels on renal function in Japanese chronic kidney disease patients with hyperlipidemia.

Methods

Of 344 participants in the ASUCA trial, 279 participants whose UA levels at both baseline and 24 months were available were included. Based on UA level at baseline or mean UA level during the trial period, they were divided into four groups: < 5.0, 5.0–6.0, 6.0–7.0, or ≥ 7.0 mg/dL, irrespective of allocation. Changes in the estimated glomerular filtration rate (eGFR) after 24 months were compared among the groups in relation to baseline or mean UA levels.

Results

For baseline UA levels (< 5.0, 5.0–6.0, 6.0–7.0, or ≥ 7.0 mg/dL), the change in eGFR after 24 months was − 1.32 ± 10.3, − 1.74 ± 8.94, − 2.53 ± 7.34, and − 3.51 ± 9.10 mL/min/1.73 m², respectively. A negative correlation between changes in eGFR after 24 months and baseline UA level was observed with adjustment for confounding factors. The relationship between changes in eGFR and mean UA levels during trial period showed a similar trend.

Conclusion

In CKD patients with dyslipidemia, hyperuricemia was an independent risk factor for CKD progression. An ongoing clinical trial (TARGET-UA, UMIN-ID 000,026,741) may reveal the significance of strict UA-lowering therapy in CKD patients.

Electronic supplementary material

The online version of this article (10.1007/s10157-019-01840-4) contains supplementary material, which is available to authorized users.

Study of association of serum uric acid with albuminuria and carotid atherosclerosis in type 2 diabetes mellitus patients

Introduction:

Type 2 diabetes mellitus is a heterogeneous group of metabolic disorders of disturbance of carbohydrate, fat, and protein metabolism causing macrovascular (like coronary artery disease) and microvascular (kidney damage) complications. Microalbuminuria is the first manifestation of injury to glomerular filtration barrier and carotid intima-media thickness (IMT) of common carotid artery serves as an excellent marker for early lesion of atherosclerosis.

Method:

A cross-sectional observational study was carried out over a period of 1.5 years in PGIMER, DR. RML Hospital, New Delhi. Patients with type 2 diabetes mellitus, aged between 35 and 60 years, were investigated for uric acid (UA), urine albumin levels, and common carotid IMT during this period. Patients on drugs that affect serum UA level, patients with acute illness, patients with serum creatinine >1.5 mg/dL, or with coronary artery disease were excluded from study.

Result:

Prevalence of hyperuricemia was found to be high (46%) in type 2 diabetic patients. It was also higher in females (73.7%) than males (25.8%). There was positive correlation between serum UA concentrations with logarithm of urine albumin excretion (P < 0.023) and carotid intima-media thickness (IMT) (P < 0.027). Plaque index also showed a positive correlation with UA (P < 0.019). However, there was no positive correlation with UA and other variable such as age, duration of diabetes, systolic blood pressure, diastolic blood pressure, HbA1c, lipid profiles, urea, and creatinine.

Conclusion:

Serum UA concentration thus serves as an early marker of renal dysfunction and cardiovascular diseases in type 2 diabetic patients.

Effect of Muntingia calabura L. Stem Bark Extracts on Uric Acid Concentration and Renal Histopathology in Diabetic Rats

Background and objectives: This study was designed to determine uric acid concentration and renal histopathology of Muntingia calabura L. stem bark extract in diabetic rats and to compare the natural product of M. calabura L. stem bark extract with allopurinol. Materials and Methods: A completely randomized design was used for the experiment, which consisted of six treatment groups, each consisting of four rats, as follows: 1) NR, normal rat; 2) KN, diabetic rat (negative control); 3) KP, diabetic rats given allopurinol 10 mg/kg body weight; 4) EM150, diabetic rats given the test extract 150 mg/kg body weight/day; 5) EM300, diabetic rats given the test extract 300 mg/kg body weight/day; and 6) EM450, diabetic rats given for extract 450 mg/kg body weight/ day. Results: The results showed that M. calabura L. stem bark extract decreased (p < 0.05) uric acid concentrations in diabetic rats and no specific damage to renal proximal tubular cells was seen. Conclusions: It was concluded that M. calabura L. stem bark extract has a potential as an antihyperuricemic in diabetic rats. The recommended dose was 300 mg/kg body weight to provide a significant effect on reducing the uric acid level in diabetic rats. Our results support the use of this plant for the treatment of degenerative and inflammatory diseases.

Serum uric acid as a risk factor of all-cause mortality and cardiovascular events among type 2 diabetes population: Meta-analysis of correlational evidence

AIMS

To explore the association between serum uric acid (SUA) level and the risk of cardiovascular complications and all-cause mortality rates among individuals with type 2 diabetes.

METHODS

Web of Science and PubMed database were searched for studies reported associations between SUA level and cardiovascular complications and all-cause mortality among individuals with type 2 diabetes. Hazard ratios (HRs) were independently extracted by two investigators and synthesized through meta-analysis across selected studies.

RESULTS

6 (n = 11,750 patients), 4 (n = 3044 patients) and 2 studies (n = 7792 patients) were identified reporting associations between SUA level and all-cause mortality, coronary heart disease (CHD) and stroke respectively. HR for all-cause mortality, CHD, and stroke per 59 μmol/l increase was 1.06 (95% CI: 1.03, 1.09), 1.09 (95% CI: 0.94, 1.26) and 1.19 (95% CI: 1.08, 1.31), respectively.

CONCLUSIONS

Overall, the SUA level was associated with a higher risk of all-cause mortality and stroke. We found no significant association between SUA level and CHD among type 2 diabetes population.

Asymptomatic hyperuricemia and incident stroke in elderly Chinese patients without comorbidities

BACKGROUND/OBJECTIVES

Hyperuricemia is usually associated with other comorbidities; so it is difficult to distinguish the effects of hyperuricemia from other coexisting comorbidities in patients who suffer a stroke.

SUBJECT/METHODS

Data for this study were collected from the patients of Kangjian Community Health Center of Shanghai. Selected participants ≥65 years of age were available at enrollment (2009-2013). Subjects were excluded if they had hypertension, diabetes mellitus, pre-existing cardiovascular disease, or hyperlipidemia. Further, patients who were overweight or obese, had gout or drug-treated hyperuricemia, or had chronic kidney disease were also excluded. Cox regression was used in order to assess the hazard ratio (HR) for the incidence of stroke events between hyperuricemic and normouricemic patients.

RESULTS

A total of 3243 subjects without comorbidities (70.8 ± 6.0 years) were followed for 35.5 ± 3.0 months. Hyperuricemia conferred increased cumulative incident stroke events (6.9 versus 3.1%, odds ratio [OR] = 2.27, 95% confidence index [CI] 1.52-3.37, p < 0.001). Male and female hyperuricemic subjects also showed a significantly higher incident stroke incidence than normouricemic subjects (6.1 versus 2.7%, OR = 2.34, 95% CI 1.31-4.18, p = 0.003 and 7.6 versus 3.7%, OR = 2.16, 95% CI 1.25-3.72, p = 0.005, respectively). Cox regression showed that hyperuricemia independently predicted incident stroke risk (HR = 2.32, 95%CI 1.56-3.45).

CONCLUSION

Asymptomatic hyperuricemia carried a significant risk of stroke events in Chinese elderly without comorbidities.

Old Drugs for New Indications in Cardiovascular Medicine

Inflammation participates in the initiation and progression of atherosclerotic cardiovascular disease, and it is a critical inciting factor leading to acute ischemic events. Evidence has shown that certain anti-inflammatory medications used to treat non-atherosclerotic inflammatory diseases reduce cardiovascular events. This article reviews evidence that commonly used anti-inflammatory therapies (colchicine, allopurinol, methotrexate), reduce cardiovascular events. We discuss potential mechanisms of action, efficacy, and safety of these therapies and propose a clinical trials design to investigate their efficacy.

Interaction between gender and uric acid on hemoglobin A1c in community-dwelling persons

INTRODUCTION

Higher glycated hemoglobin (Hb) (HbA1c) is significantly associated with an increased risk of cardiovascular disease (CVD). Serum uric acid (SUA) levels are associated with glucose intolerance and type 2 diabetes. Whether gender-specific differences regarding the relationship between SUA levels and HbA1c exist is unknown.

AIM

We recruited 1636 (men, 696 aged of 70 ± 10 years; women, 940 aged of 70 ± 9 years) participants and enrolled in the study during their annual health examination from a single community. We investigated the association between SUA levels and HbA1c within each gender.

RESULTS

Multiple linear regression analysis showed that in men, SUA (β = -0.091, p = 0.014) with prevalence of antidiabetic medication (β = 0.428, p < 0.001) and eGFR (β = 0.112, p = 0.016) were significantly and negatively associated with HbA1c, and in women, SUA (β = 0.101, p = 0.002) with prevalence of antidiabetic medication (β = 0.458, p < 0.001) were significantly and positively associated with HbA1c. Moreover, the interaction between gender and SUA (β = 0.445, p < 0.001) as well as gender (β = -0.465, p < 0.001), prevalence of antidiabetic medication (β = 0.444, p < 0.001), eGFR_CKDEPI (β = 0.074, p = 0.014), and SUA (β = -0.356, p < 0.001) was a significant and independent determinant of HbA1c. A significant interactive effect of gender and SUA on determinants of HbA1c was noted in patients not on antidiabetic medications, regardless of age, HbA1c, and renal function.

CONCLUSIONS

The interaction between gender and SUA was associated with HbA1c independent of other metabolic factors in community-dwelling persons.

Association of serum uric acid with nephropathy in Iranian type 2 diabetic patients

Background

Diabetic nephropathy (DN) is the major cause of end-stage renal disease. Recent studies suggest that it is probable that uric acid is involved in the pathogenesis of diabetic nephropathy. This study aim was to investigate the association between serum uric acid and kidney function in Iranian patients with type 2 diabetes mellitus.

Methods

In this case-control study, a total of 201 diabetic patients with or without impaired kidney function (glomerular filtration rate/GFR < 60 and GFR ≥ 60) were selected. In both groups, serum fasting glucose (FBS), HbA1c, urea, creatinine, uric acid and lipid profile, urine albumin and GFR were measured and results were compared between the two groups. The results also categorized into three groups based on uric acid tertiles.

Results

Serum levels of uric acid, urea and creatinine as well as urine albumin/creatinine ratio (ACR) were significantly different between the two groups. GFR, creatinine and also urea were significantly different between uric acid tertiles (p < 0.05).

Conclusions

Serum uric acid is associated with decreased GFR as well as albuminuria and can be used as an indicator of DN.

Urate-Lowering Therapy Ameliorates Kidney Function in Type 2 Diabetes Patients With Hyperuricemia

Background

Hyperuricemia often causes kidney dysfunction which increases serum urate, forming a vicious cycle in the kidney. In this study, urate-lowering therapy was demonstrated in type 2 diabetic patients with hyperuricemia to evaluate the effect on diabetic nephropathy.

Methods

Type 2 diabetic patients with hyperuricemia (n = 34) were treated by urate-lowering drugs. Serum urate levels, estimated glomerular filtration rate (eGFR), blood pressure, HbA1c, and urinary albumin-to-creatinine ratio (UACR) were measured for 52 weeks. The parameters at the endpoint when serum urate decreased to below 6.0 mg/dL and at 52 weeks were compared to the initial levels at week 0.

Results

Serum urate level decreased to the endpoint in all patients and was maintained at under 6.0 mg/dL throughout the observation period. eGFR significantly increased at the endpoint and also at 52 weeks. Overall UACR did not change after 52 weeks; however, the treatment decreased UACR significantly in patients with no microalbuminuria. There was a negative relationship between the change of serum urate levels and the change of eGFR, and a negative relationship between the baseline UACR and the change of UACR when patients with macroalbuminuria were excluded. There were no changes in HbA1c levels and blood pressure before and after the treatment.

Conclusions

There were significant improvements in kidney function by lowering serum urate levels to under 6.0 mg/dL and the effect was maintained for at least 52 weeks. This treatment may be one strategy to slow the progression of nephropathy in type 2 diabetic patients with hyperuricemia.

Asymptomatic hyperuricemia and coronary artery disease in elderly patients without comorbidities

Because many subjects with hyperuricemia have comorbidities, it can be difficult to differentiate the role of hyperuricemia from that of other comorbidities of coronary artery disease (CAD). Subjects aged ≥ 65 years were enrolled in the study and were available at enrollment and at 5-year follow-up. Subjects were excluded if they were overweight or obese, hypertensive, diabetic, hyperlipidemic, had a pre-existing cardiovascular disease, a history of gout or hyperuricemia on medications, or chronic kidney disease as estimated by a glomerular filtration rate (eGFR) < 60 mL/min per 1.73 m². We used Poisson regression to estimate the hazard ratio (HR) for incident CAD events between hyperuricemic (> 7 mg/dL in men and ≥ 6 mg/dL in women) and normouricemic subjects. A total of 2,142 subjects without comorbidities (mean age of 70.7 ± 5.9 years, 1,194 men) were followed for 57.4 ± 8.9 months. Hyperuricemia was associated with an increased cumulative incidence of incident CAD events (15.0% versus 8.8%, P < 0.001). After adjusting for confounding factors, hyperuricemia independently predicted the risk of incident CAD events (HR=1.71, 95% CI 1.26-2.34). In conclusion, asymptomatic hyperuricemia is a valuable biomarker for predicting the development of incident CAD events.

Effects of Sodium Glucose Cotransporter-2 Inhibitors on Serum Uric Acid in Type 2 Diabetes Mellitus

Hyperuricemia has been linked to metabolic syndrome, cardiovascular disease, and chronic kidney disease. Hyperuricemia and type 2 diabetes mellitus were inter-related, type 2 diabetes mellitus was more at risk of having a higher serum uric acid level, and also individuals with higher serum uric acid had higher risk of developing type 2 diabetes in the future. Insulin resistance seems to play an important role in the causal relationship between metabolic syndrome, type 2 diabetes, and hyperuricemia. Oral diabetic drugs that would have additional beneficial effects on reducing serum uric acid levels are of importance. Selective SGLT2 inhibitors were extensively studied in type 2 diabetes mellitus and were found to have improvement of glycemic control, in addition to their proven metabolic effects on weight and blood pressure. Additional beneficial effect of SGLT2 inhibitors on serum uric acid level reduction is investigated. Recently, data have been accumulating showing that they have additional beneficial effects on serum uric acid reduction. As for the postulated mechanism, serum uric acid decreased in SGLT2 inhibitor users as a result of the increase in the urinary excretion rate of uric acid, due to the inhibition of uric acid reabsorption mediated by the effect of the drug on the GLUT9 isoform 2, located at the collecting duct of the renal tubule.

Effects of canagliflozin on cardiovascular risk factors in patients with type 2 diabetes mellitus

BACKGROUND AND AIMS

Cardiovascular disease is the most common cause of morbidity and mortality among people with type 2 diabetes mellitus (T2DM). The main contributors to cardiovascular risk in T2DM are chronic hyperglycaemia, reduced insulin sensitivity, hypertension and dyslipidaemia. Other cardiovascular risk factors include obesity and visceral adiposity, increased arterial stiffness and renal dysfunction. Results from clinical trials, including a long-term cardiovascular outcome study, have shown that sodium glucose co-transporter 2 (SGLT2) inhibitors can provide multiple cardiometabolic benefits beyond glycaemic control including inducing mild osmotic diuresis, natriuresis and weight loss. This review article describes the effects of canagliflozin on cardiovascular risk factors based on results from its clinical development programme.

METHODS

This review is based on structured searches to identify literature related to the effects of canagliflozin on cardiovascular risk factors in patients with T2DM.

DISCUSSION AND CONCLUSIONS

Canagliflozin treatment has been shown to provide glycaemic improvements as well as reductions in blood pressure and body weight across a broad range of patients with T2DM, including those with elevated cardiovascular risk. Other observed effects of canagliflozin that may contribute to improved cardiometabolic outcomes include reduction in uric acid levels, decreased albuminuria and increases in serum magnesium. Results of ongoing long-term cardiovascular outcomes studies of canagliflozin are expected to provide additional evidence on the cardiometabolic effects of canagliflozin treatment.

Dapagliflozin: potential beneficial effects in the prevention and treatment of renal and cardiovascular complications in patients with type 2 diabetes

INTRODUCTION

Diabetic kidney disease is the leading cause of end-stage renal disease, a significant contributor to cardiovascular (CV) disease, responsible for much of the morbidity and mortality in patients with type 2 diabetes (T2DM). Strategies to slow or prevent the onset and progression of diabetic kidney disease are critical for effectively managing T2DM and reducing CV risk. Sodium-glucose cotransporter 2 (SGLT2) inhibitors are effective antidiabetic agents, which may provide nephroprotective and CV protective effects. Areas covered: This review examines the role of the kidney in glucose homeostasis, discusses renal hemodynamic changes in diabetes, and outlines the major hypotheses regarding the mechanisms underlying renal injury in diabetes. The potential benefits of SGLT2 inhibitors in the prevention and treatment of CV complications in patients with T2DM are reviewed, with particular focus on dapagliflozin. Expert opinion: Dapagliflozin and other SGLT2 inhibitors have the capacity to decrease hyperglycemia and visceral fat, components of the metabolic syndrome particularly associated with the progression of CV disease. However, the mechanisms of action of SGLT2 inhibitors resulting in their positive CV effects remain unclear. Furthermore, the mechanism of action of SGLT2 inhibitors on heart function in non-diabetic patients with decompensated heart failure remains to be explored.

On the non-linear association between serum uric acid levels and all-cause mortality rate in patients with type 2 diabetes mellitus

BACKGROUND AND AIMS

High levels of serum uric acid (SUA) are associated with increased mortality risk in the general population. Contrasting results are available in people with diabetes. The aim of our study was to investigate the association and its functional form between SUA and all cause-mortality in patients with type 2 diabetes mellitus (T2DM).

METHODS

We studied three cohorts of patients with T2DM: Gargano Mortality Study, Foggia Mortality Study, Pisa Mortality Study. All-cause mortality rate was the end point of this study.

RESULTS

The most reliable relationship between SUA levels and all-cause mortality rate was quadratic, with such model being well approximated by SUA tertiles. Both tertiles 1 and 3 were at higher risk of mortality as compared to tertile 2: Hazard Ratio (HR) [95% Confidence Interval (CI)] = 1.34 (1.07-1.68) and 1.61 (1.29-1.99), respectively. In the pseudo-sample, created from the real pooled sample, the best relationship between SUA and all-cause mortality rate was quadratic. In a tree-based Recursive Partitioning and Regression Tree analysis two subgroups at increased risk of mortality were identified, namely those with SUA levels ≥7.28 mg/dl and with SUA levels <4.16 mg/dl as compared to patients with intermediate SUA levels (i.e. 4.16-7.28), thus providing further evidence on the J-shaped relationship between SUA levels and mortality rate.

CONCLUSIONS

SUA was not linearly associated with all-cause mortality rate in patients with T2DM. For clinical and public health purposes such association is J-shaped.

The next generation of therapeutics for chronic kidney disease

Chronic kidney disease (CKD) represents a leading cause of death in the United States. There is no cure for this disease, with current treatment strategies relying on blood pressure control through blockade of the renin-angiotensin system. Such approaches only delay the development of end-stage kidney disease and can be associated with serious side effects. Recent identification of several novel mechanisms contributing to CKD development - including vascular changes, loss of podocytes and renal epithelial cells, matrix deposition, inflammation and metabolic dysregulation - has revealed new potential therapeutic approaches for CKD. This Review assesses emerging strategies and agents for CKD treatment, highlighting the associated challenges in their clinical development.

Gout and diabetes: a common combination

The aims of this cross-sectional study were to compare metabolic parameters in people with gout and diabetes with gout only and type 2 diabetes mellitus (T2DM) only. Fifty General Practices in NHS Ayrshire and Arran (population 340 377) contributed data. The sample was split into three groups, those with both gout and T2DM, those with gout only and those with T2DM only. The prevalence of gout in Ayrshire and Arran was 2.65%. The prevalence of gout in people with type 1 and 2 diabetes was 1.90% (p=0.30) and 10.12% (p<10(-5)), respectively. Patients with both conditions were significantly more likely to be male (p<10(-5)), older (p<10(-5)), have a higher mean body mass index (p<0.001), higher triglycerides (p<10(-4)), lower mean total, high-density lipoprotein- and low-density lipoprotein cholesterol (p<10(-5)), lower estimated glomerular filtration rate (p<0.001), neuropathy (p=0.02), lower haemoglobin (p<0.001), to be prescribed more medications (p<10(-5)) and less likely to smoke (p<0.01). There was an association between lower haemoglobin A1c and increased prevalence of gout (p<0.001). 42.4% of patients with gout alone and 36.2% of those with both gout and diabetes had a urate measure. This study defines much more clearly the association between gout and T2DM. Of interest, in terms of lifestyle, both better glycaemic control and smoking are associated with a higher prevalence of gout.

Comparison of the Renoprotective Effect of Febuxostat for the Treatment of Hyperuricemia between Patients with and without Type 2 Diabetes Mellitus: A Retrospective Observational Study

Objective The effects of febuxostat therapy on hyperuricemia in patients with and without type 2 diabetes were compared in this retrospective observational study after pair-matching using the propensity scores. Methods In total, 160 patients with hyperuricemia were studied as the treated set, and the 155 subjects in whom the administration of febuxostat was not discontinued during the observation period were investigated in the full analysis. The study subjects were divided into two groups based on the style of initiation of febuxostat: initial and switching therapy from allopurinol administration. Results The reduction in the serum uric acid (sUA) levels at six months after the initiation of febuxostat administration did not significantly differ between the patients with and without diabetes in both the initial (206±114 and 226±113 μmol/L in patients with and without diabetes, respectively) and switching (154±91 and 129±90 μmol/L in patients with and without diabetes, respectively) therapy groups. The eGFR values were significantly increased compared to the baseline levels only in the patients without diabetes. The changes in the eGFR values were significantly associated with the presence of diabetes and sUA at baseline in a multivariate analysis. The frequency of adverse events was not significantly different between the patients with and without diabetes. Conclusion Although febuxostat exerted a similar sUA-lowering effect against hyperuricemia in patients with type 2 diabetes compared to those without, the renoprotective effect was attenuated in those with diabetes compared to nondiabetic subjects.

Management of Chronic Kidney Disease: The Relationship Between Serum Uric Acid and Development of Nephropathy

Chronic kidney disease (CKD) is increasingly recognized as a global health problem, and new and effective strategies are needed for the management of this condition. Recently, there has been renewed interest in the relationship between serum uric acid (SUA) levels and CKD, and several recent trials have demonstrated a possible link between SUA and the development and/or progression of CKD in patients with and without diabetes. The identification of key urate transporters such as urate transporter 1 and glucose transporter 9 has provided not only insights into the pathophysiology of hyperuricemia, but also possible links to other processes, such as glucose homeostasis. The renewed interest in the role of SUA in CKD has coincided with the development of sodium glucose co-transporter 2 inhibitors for the treatment of diabetes. In addition to improving glycemic control, these agents, acting via the kidneys in an insulin-independent manner, have also been shown to reduce SUA levels and potentially improve some measures of renal function. This review will discuss the role of uric acid in CKD treatment, and how SUA-lowering therapies may prevent or delay the progression of CKD.

FUNDING

Janssen Scientific Affairs.

Allopurinol treatment improves renal function in patients with type 2 diabetes and asymptomatic hyperuricemia: 3-year randomized parallel-controlled study

OBJECTIVE

To investigate the effects of long-term effective control of serum uric acid on renal function in patients with type 2 diabetes and asymptomatic hyperuricemia.

METHODS

Application of randomized open parallel-controlled methods, a total of 176 patients with type 2 diabetes and asymptomatic hyperuricemia were selected, and was randomly divided into two groups for allopurinol or conventional treatments, respectively. Changes in urinary albumin excretion rate (UAER), the levels of serum creatinine and glomerular filtration rate (GFR) and the incidence of new-onset diabetic nephropathy (DN) and hypertension in patients before and after 3 years of treatment were measured and compared between groups.

RESULTS

There were no statistically significant difference in the baseline clinical characteristics of study participants between two treatment groups (P > 0·05 for all). After 3 years of treatment, compared to the conventional treatment, the allopurinol treatment was more effective in reducing serum uric acid, UAER, serum creatinine (P < 0·01 for all) and increasing GFR (P < 0·01). The intention-to-treat (ITT) analysis indicated that the incidence of new-onset DN and hypertension in the allopurinol group showed a declining trend compared to that in the conventional treatment group, despite a lack of significant difference (P > 0·05).

CONCLUSION

Long-term effective control of serum uric acid can decrease UAER and serum creatinine, increase GFR and may exert kidney protection effects in patients with type 2 diabetes and asymptomatic hyperuricemia.

Uric Acid is independently associated with diabetic kidney disease: a cross-sectional study in a Chinese population

BACKGROUND

Association between hyperuricaemia and chronic kidney disease has been studied widely, but the influence of uric acid on the kidneys remains controversial. We aimed to summarize the association between uric acid and diabetic kidney disease (DKD), and to evaluate the role of uric acid in DKD.

METHODS

We enrolled 3,212 type 2 diabetic patients in a cross-sectional study. The patients' basic characteristics (sex, age, BMI, duration of disease, and blood pressure) and chemical parameters (triglycerides, total cholesterol, low-density lipoprotein cholesterol (LDL-c), high-density lipoprotein cholesterol (HDL-c), microalbuminuria, creatinine, and uric acid) were recorded, and the association between uric acid and DKD was evaluated.

RESULTS

In the 3,212 diabetic patients, the prevalence of diabetic kidney disease was higher in hyperuricaemic patients than in patients with normouricaemia (68.3% vs 41.5%). The prevalence of DKD increased with increasing uric acid (p < 0.0001). Logistic analysis identified uric acid as an independent predictor of DKD (p < 0.0001; adjusted OR (95%CI) = 1.005 (1.004-1.007), p < 0.0001). Uric acid was positively correlated with albuminuria and creatinine levels (p < 0.0001) but negatively correlated with eGFR (p < 0.0001) after adjusting for confounding factors.

CONCLUSIONS

Hyperuricaemia is a risk factor for DKD. Serum uric acid levels within the high-normal range are independently associated with DKD.

Use of Contrast-Enhanced Ultrasound to Study Relationship between Serum Uric Acid and Renal Microvascular Perfusion in Diabetic Kidney Disease

Purpose. To investigate the relationship between uric acid and renal microvascular perfusion in diabetic kidney disease (DKD) using contrast-enhanced ultrasound (CEUS) method. Materials and Methods. 79 DKD patients and 26 healthy volunteers were enrolled. Renal function and urine protein markers were tested. DKD patients were subdivided into two groups including a normal serum uric acid (SUA) group and a high SUA group. Contrast-enhanced ultrasound (CEUS) was performed, and low acoustic power contrast-specific imaging was used for quantitative analysis. Results. Normal controls (NCs) had the highest levels of AUC, AUC1, and AUC2. Compared to the normal SUA DKD group, high SUA DKD patients had significantly higher IMAX, AUC, and AUC1 (P < 0.05). DKD patients with low urinary uric acid (UUA) excretion had significantly higher AUC2 compared to DKD patients with normal UUA (P < 0.05). Conclusion. Hyperuricemia in DKD patients was associated with a renal ultrasound image suggestive of microvascular hyperperfusion. The CEUS parameter AUC1 holds promise as an indicator for renal microvascular hyperperfusion, while AUC2 might be a useful indicator of declining glomerular filtration rate in DKD patients with decreased excretion of uric acid.

Effect of canagliflozin on serum uric acid in patients with type 2 diabetes mellitus

Hyperuricaemia is associated with an increased risk of gout, kidney stones and cardiovascular disease. The present post hoc analysis of pooled data from four placebo-controlled phase III studies assessed the effect of canagliflozin, a sodium-glucose co-transporter 2 inhibitor, on serum uric acid levels in patients with type 2 diabetes mellitus (T2DM) and in a subset of patients with hyperuricaemia [defined as baseline serum uric acid ≥475 µmol/l (∼8 mg/dl)]. At week 26, canagliflozin 100 and 300 mg were associated with a ∼13% reduction in serum uric acid compared with placebo. In the subset of patients with hyperuricaemia, placebo-subtracted percent reductions in serum uric acid were similar to those in the overall cohort. More patients in the hyperuricaemic group achieved a serum uric acid level of <360 µmol/l (∼6 mg/dl) with both canagliflozin 100 mg (23.5%) and 300 mg (32.4%) compared with placebo (3.1%). Incidences of gout and kidney stones were low and similar across groups. In conclusion, canagliflozin treatment decreased serum uric acid in patients with T2DM, including those with baseline hyperuricaemia.

Diagnostic value of quantitative contrast-enhanced ultrasound (CEUS) for early detection of renal hyperperfusion in diabetic kidney disease

PURPOSE

To investigate the diagnostic value of quantitative contrast-enhanced ultrasound (CEUS) for early detection of renal hyperperfusion in diabetic kidney disease (DKD).

MATERIALS AND METHODS

55 DKD patients with estimated glomerular filtration rate (eGFR) >30 ml/min/1.73 m(2) and 26 normal controls (NCs) were enrolled. Clinical data was well documented. Blood samples were drawn for evaluation of renal function including blood urea nitrogen (BUN), serum creatinine (SCr) and serum uric acid (SUA), and urine samples were assayed for total protein quantification, and various microprotein markers. According to eGFR level, DKD patients were divided into early-stage DKD (eGFR ≥90 ml/min/1.73 m(2), n = 18) and middle-stage DKD (eGFR 30-90 ml/min/1.73 m(2), n = 37). Based on urinary microalbumin/creatinine ratio (MALB/UCR), early-stage DKD patients were further classified into two groups: MALB/UCR <10 g/mol (n = 11) and MALB/UCR ≥10 g/mol (n = 7). Then, CEUS was performed to observe the real-time renal perfusion, and low acoustic power contrast-specific imaging was used for quantitative analysis.

RESULTS

The renal perfusion images of CEUS were well developed successively. The corresponding perfusion curves based on echo-power signals in time series were constructed. Quantitative analysis showed that area under the descending curve (AUC2) was significantly increased in early-stage DKD compared to middle-stage DKD (p < 0.05), but AUC showed no significant difference. Further comparison between different MALB/UCR levels of early-stage DKD showed that patients with MALB/UCR ≥10 g/mol had significantly increased levels of AUC, AUC2 and proteinuria than patients with low MALB/UCR (p < 0.05). Also, high MALB/UCR DKD patients had increased proteinuria but similar eGFR compared to low MALB/UCR patients.

CONCLUSION

Renal microvascular hyperperfusion may be responsible for overt proteinuria until decline of renal filtration in DKD. AUC2 could be an early and sensitive marker for early renal injury and renal microvascular hyperperfusion in DKD.

Serum Uric Acid Levels and Diabetic Peripheral Neuropathy in Type 2 Diabetes: a Systematic Review and Meta-analysis

Previous studies suggested a possible association between serum uric acid levels and peripheral neuropathy in patients with type 2 diabetes, but no definite evidence was available. A systematic review and meta-analysis of relevant studies were performed to comprehensively estimate the association. Pubmed, Web of Science, Embase, and China Biology Medicine (CBM) databases were searched for eligible studies. Study-specific data were combined using random-effect or fixed-effect models of meta-analysis according to between-study heterogeneity. Twelve studies were finally included into the meta-analysis, which involved a total of 1388 type 2 diabetic patients with peripheral neuropathy and 4746 patients without peripheral neuropathy. Meta-analysis showed that there were obvious increased serum uric acid levels in diabetic patients with peripheral neuropathy (weighted mean difference [WMD] = 50.03 μmol/L, 95% confidence interval [95%CI] 22.14-77.93, P = 0.0004). Hyperuricemia was also significantly associated with increased risk of peripheral neuropathy in patients with type 2 diabetes (risk ratio [RR] = 2.83, 95%CI 2.13-3.76, P < 0.00001). Meta-analysis of two studies with adjusted risk estimates showed that hyperuricemia was independently associated with increased risk of peripheral neuropathy in type 2 diabetic patients (RR = 1.95, 95%CI 1.23-3.11, P = 0.005). Type 2 diabetic patients with peripheral neuropathy have obvious increased serum uric acid levels, and hyperuricemia is associated with increased risk of peripheral neuropathy. Further prospective cohort studies are needed to validate the impact of serum uric acid levels on peripheral neuropathy risk.

Increased serum uric acid levels are correlated with decreased left atrial appendage peak flow velocity in patients with atrial fibrillation

OBJECTIVE

We aimed to examine the relationship between serum uric acid levels and left atrial appendage (LAA) peak flow velocity, an indicator of the mechanical functions of the LAA, and atrial fibrillation (AF).

SUBJECTS AND METHODS

Transesophageal echocardiography was performed before cardioversion in 153 patients with AF. The patients were categorized into 2 groups based on their LAA blood flow velocity. Group 1 included 87 patients with a low LAA flow velocity (<35 cm/s), and group 2 comprised 66 patients with a normal LAA flow velocity (≥35 cm/s). The χ(2) and Student's t tests were used to compare categorical and quantitative data between the groups. Linear regression analyses were performed to demonstrate the independent association between serum uric acid levels and LAA peak flow velocity.

RESULTS

The LAA blood flow velocity was 24.62 ± 5.90 cm/s in group 1 and 49.28 ± 13.72 cm/s in group 2, respectively (p < 0.001). The serum uric acid levels were 6.88 ± 1.85 mg/dl in group 1 and 5.97 ± 1.51 mg/dl in group 2, and the difference was statistically significant (p = 0.001). There was a negative correlation between serum uric acid levels and LAA blood flow velocity (r = -0.216, p = 0.007). Multivariate regression analysis showed that serum uric acid levels, age and gender differences were significant predictors of the LAA peak flow velocity.

CONCLUSIONS

High serum uric acid levels were associated with a low contractile function of the LAA and could provide additional prognostic information on future thromboembolic events in patients with AF.