Prediction of tumor lysis syndrome in childhood acute lymphoblastic leukemia based on machine learning models: a retrospective study

Background

Tumor lysis syndrome (TLS) often occurs early after induction chemotherapy for acute lymphoblastic leukemia (ALL) and can rapidly progress. This study aimed to construct a machine learning model to predict the risk of TLS using clinical indicators at the time of ALL diagnosis.

Methods

This observational cohort study was conducted at the National Clinical Research Center for Child Health and Disease. Data were collected from pediatric ALL patients diagnosed between December 2008 and December 2021. Four machine learning models were constructed using the Least Absolute Shrinkage and Selection Operator (LASSO) to select key clinical indicators for model construction.

Results

The study included 2,243 pediatric ALL patients, and the occurrence of TLS was 8.87%. A total of 33 indicators with missing values ≤30% were collected, and 12 risk factors were selected through LASSO regression analysis. The CatBoost model with the best performance after feature screening was selected to predict the TLS of ALL patients. The CatBoost model had an AUC of 0.832 and an accuracy of 0.758. The risk factors most associated with TLS were the absence of potassium, phosphorus, aspartate transaminase (AST), white blood cell count (WBC), and urea levels.

Conclusion

We developed the first TLS prediction model for pediatric ALL to assist clinicians in risk stratification at diagnosis and in developing personalized treatment protocols. This study is registered on the China Clinical Trials Registry platform (ChiCTR2200060616).

Clinical trial registration

https://www.chictr.org.cn/, identifier ChiCTR2200060616.

Onconephrology: mitigation of renal injury in chemotherapy administration

PURPOSE OF REVIEW

Onconephrology was first coined as a name for the intersection of cancer medicine and nephrology in the early 2010s. It was recognized then that beyond and understanding of kidney physiology, a new generation of nephrologists skilled in both molecular biology and precision medicine were needed to deal with the challenges of emerging cancer therapies. Stem cell transplants, biologic agents, adjuvants blocking basic cellular signaling pathways, immunotherapy were found to promote novel anticancer outcomes, but also to pose new risks to the kidneys. The field rapidly overlapped with emerging expertise in vascular glomerular disease, glomerular disease, and the same biologic agents now applied to auto immune systemic and kidney diseases.

RECENT FINDINGS

Many categories of chemotherapeutic agents have been discovered to have adverse renal side effects. In this review, we address classic chemotherapeutic nephrotoxicity and oncologic clinical situations leading to acute kidney injury. We also review the frontiers of nephrotoxicity reported with cell cycle inhibitors, diverse classes of tyrosine kinase inhibitors, immune checkpoint inhibitors, chimeric antigen receptor T-cell therapy, anticancer vaccines, and thrombotic microangiopathies triggered by malignancy and chemotherapy. The aim will be to focus on published strategies to mitigate nephrotoxicity.

SUMMARY

As onconephrology expands into its own field, it gives birth to new subdisciplines. An understanding that patient populations want the benefits of chemotherapy without the renal (and other) systemic toxicities is emerging. A need to develop a new class of molecular and genetic experts in onconephrology to mitigate nephrotoxicity from chemotherapy is apparent and urgent.

Use of rasburicase to improve kidney function in children with hyperuricemia and acute kidney injury

BACKGROUND

Hyperuricemia contributes to decrease in kidney function and induces additional renal damage in children with acute kidney injury (AKI). Rasburicase oxidizes uric acid (UA), decreasing its serum quantities in less than 24 h.

METHODS

This is a retrospective study involving hospitalized patients under 18 years of age with underlying pathology diagnosed with AKI and severe hyperuricemia treated with rasburicase over a 4-year period.

RESULTS

We describe 15 patients from 4 days of life to 18 years (median: 4.4 years). Seventy-three percent had known underlying pathologies. All presented worsening of basal renal function or AKI data. All received the usual medical treatment for AKI without response. Twenty percent received an extrarenal depuration technique. All had hyperuricemia with a mean (± SD) of 13.1 (± 2.19) mg/dl. After rasburicase administration UA levels fell to a mean (± SD) of 0.76 (± 0.62) mg/dl (p < 0.001) in less than 24 h. In parallel, a decrease in the mean plasma creatinine was observed (2.92 mg/dl to 1.93 mg/dl (p = 0.057)) together with a significant improvement of the mean glomerular filtration rate (16.3 ml/min/1.73 m2 to 78.6 ml/min/1.73 m2) (p = 0.001)). No side effects were recorded. Kidney function normalized in all cases or returned to baseline levels.

CONCLUSIONS

Although the use of rasburicase is not routinely approved in pediatric patients with severe hyperuricemia and AKI, it has been used successfully without complications, and helped prevent progressive kidney damage. This study could serve as a basis for suggesting the off-label use of rasburicase for the management of complex pediatric patients in whom UA plays an important role in the development of AKI.

The Onco-Nephrology Field: The Role of Personalized Chemotherapy to Prevent Kidney Damage

In recent years, the onco-nephrology field has acquired a relevant role in internal medicine due to the growing number of cases of renal dysfunction that have been observed in cancer patients. This clinical complication can be induced by the tumor itself (for example, due to obstructive phenomena affecting the excretory tract or by neoplastic dissemination) or by chemotherapy, as it is potentially nephrotoxic. Kidney damage can manifest as acute kidney injury or represent a worsening of pre-existing chronic kidney disease. In cancer patients, physicians should try to set preventive strategies to safeguard the renal function, avoiding the concomitant use of nephrotoxic drugs, personalizing the dose of chemotherapy according to the glomerular filtration rate (GFR) and using an appropriate hydration therapy in combination with nephroprotective compounds. To prevent renal dysfunction, a new possible tool useful in the field of onco-nephrology would be the development of a personalized algorithm for the patient based on body composition parameters, gender, nutritional status, GFR and genetic polymorphisms.

Acute kidney injury following induction of chemotherapy: Diagnosis and management in critical care

A 48-year-old gentleman who had recently commenced chemotherapy for diffuse B-cell lymphoma was admitted to hospital with nausea and generalised weakness. He developed abdominal pain and oliguric acute kidney injury with multiple electrolyte derangements and was transferred to the intensive care unit (ICU). His condition deteriorated, requiring endotracheal intubation and renal replacement therapy (RRT). Tumour lysis syndrome (TLS) is a common and life-threatening complication of chemotherapy and represents an oncological emergency. TLS affects multiple organ systems and is best managed in the ICU with closer monitoring of fluid balance, serum electrolytes, cardiorespiratory and renal function. TLS patients may go on to require mechanical ventilation and RRT. TLS patients require input from a large multidisciplinary team of clinicians and allied health professionals.

Effectiveness and Safety of Allopurinol, Febuxostat, and Rasburicase in the Prevention of Tumor Lysis Syndrome: A Systematic Review and Network Meta-analysis

Although prevention is vital in managing tumor lysis syndrome (TLS), no study directly compares various regimens. This study compared the effectiveness and safety of urate-lowering agents in preventing TLS. Databases were searched for randomized controlled trials involving adults with hematologic or solid malignancies on chemotherapy or cytoreductive agents given allopurinol, febuxostat, or rasburicase alone or in combination at any dose, form, or frequency published in English by December 2021. Outcomes included laboratory and clinical TLS expressed as relative risks, adverse events as described by authors, and mean serum uric acid (sUA) as mean differences of area under the curve. A network of meta-analysis and post-hoc meta-analysis based on TLS risk using a random-effects model was done using Stata 14.0 and Review Manager 5.3, respectively. Certainty of evidence was assessed using the GRADE approach. Three studies with a total of 633 participants given allopurinol, febuxostat, rasburicase, or rasburicase combined with allopurinol were included. Rasburicase is more effective than allopurinol in preventing laboratory TLS (relative risk: 0.51; 95% confidence interval [CI]: 0.32–0.81) based on moderate quality evidence. No significant differences were observed in clinical TLS. Adverse events were attributable to toxicities of chemotherapy. Rasburicase alone or in combination with allopurinol was better than allopurinol or febuxostat alone in reducing sUA level. Febuxostat is more effective than allopurinol in lowering sUA levels among patients at high-risk of TLS (mean difference −125.75; 95% CI: −223.47 to −28.02). Rasburicase may be the most effective agent in preventing laboratory TLS and maintaining low sUA levels.

Disorders of Divalent Ions (Magnesium, Calcium, and Phosphorous) in Patients With Cancer

Disorders of the divalent ions (magnesium, calcium, and phosphorous) are frequently encountered in patients with cancer. Of these, hypomagnesemia, hypocalcemia, hypercalcemia, and hypophosphatemia are seen most commonly. These electrolyte disturbances may be related to the underlying malignancy or due to side effects of anticancer therapy. When caused by a paraneoplastic process, these abnormalities may portend a poor prognosis. Importantly, the development of severe electrolyte derangements may be associated with symptoms that negatively impact quality of life, preclude the administration of critical chemotherapeutic agents, or lead to life-threatening complications that require hospitalization and emergent treatment. In accordance, prompt recognition and treatment of these disorders is key to improving outcomes in patients living with cancer. This review will discuss selected derangements of the divalent ions seen in this population, with a focus on paraneoplastic and therapy-associated etiologies.

Predictors of laboratory spontaneous tumour lysis syndrome in children with high-grade tumours in Uganda

High-grade malignancy is endemic in sub-Saharan Africa and is prone to the spontaneous tumour lysis syndrome. However, data on spontaneous tumour lysis syndrome remain scanty in our setting. We sought to determine the prevalence and factors associated with laboratory spontaneous tumour lysis syndrome in children in Uganda. We conducted a cross-sectional study among children <18 years old with histologically confirmed high-grade malignancy between October 2013 and April 2014. Laboratory spontaneous tumour lysis syndrome was defined as the presence of ≥2 of each of hyperkalaemia, hypocalcaemia, hyperuricaemia and hyperphosphatemia prior to administration of chemotherapy when alternative diagnoses had been excluded. A p < 0.05 was considered statistically significant. Of 108 children, of median age 7.7 years, where boys outnumbered girls 2:1, high-grade, malignancy included Burkitt's lymphoma, acute lymphoblastic leukaemia, non-Hodgkin's lymphoma, acute myeloid leukaemia and Burkitt's leukaemia, with 14 suffering with laboratory spontaneous tumour lysis syndrome. Hypocalcaemia was its most common electrolyte imbalance; and four children died prior to commencement of chemotherapy. Bulky disease, lactate dehydrogenase levels ≥500 iu/l and serum creatinine levels >1.2 mg/dl were associated with laboratory spontaneous tumour lysis syndrome. However, only bulky disease was significantly predictive of laboratory spontaneous tumour lysis syndrome. Such children would benefit from routine screening.

Relapse, Mortality, and the Associated Factors in Children with Acute Lymphoblastic Leukemia; A Competing Risks Analysis

Background: Acute lymphoblastic leukemia (ALL) is the most frequent form of malignant neoplasia diagnosed in ages 0 to 14 years old. Efforts have not yet converted into a better prospect. Bone marrow relapse is still the leading cause of person-year of life lost in this malignancy. Objectives: This study aimed at identifying the associated risk factors for relapse and mortality for pediatric patients with ALL in standard and high-risk groups. Methods: This study included a cohort of pediatric (0 - 16 years old) patients with ALL referred to Sheikh Hospital, Mashhad, Iran from 2007 to 2016. The demographic, clinical, and laboratory information were considered. Hazard ration (HR) with 95% highest posterior density region was obtained, using a Bayesian competing risks model. Results: Of 424 patients with a mean age of 5.56 ± 3.75 years, 172 (40%) were female. Median follow-up time was 43.29 months, 10.6% had a relapse, and 17.2% had mortality related to ALL. Relapse-free survival rates at 1, 3, and 5 years were 97, 91, and 88%, respectively. Overall survival rates were 86, 83, and 82%, respectively. In the standard-risk group, tumor lysis syndrome (TLS) significantly increased either the relapse risk [HR: 13.47 (2.05 - 67.54)] or mortality risk [HR: 19.57 (2.24 - 32.18)]. In the high-risk group, the higher level of hemoglobin, platelet, and lactic acid dehydrogenase was significantly associated with higher relapse risk. TLS was associated with a higher risk of mortality in high-risk groups. Conclusions: It was suggested that TLS was a predictor for the disease relapse as well as mortality in pediatric patients with ALL. However, further evaluation on the larger population of patients is demanded to ascertain the precision of such parameters in leukemic management strategies.

Clinical characteristics of tumor lysis syndrome in childhood acute lymphoblastic leukemia

Tumor lysis syndrome (TLS) is a common and fatal complication of childhood hematologic malignancies, especially acute lymphoblastic leukemia (ALL). The clinical features, therapeutic regimens, and outcomes of TLS have not been comprehensively analyzed in Chinese children with ALL. A total of 5537 children with ALL were recruited from the Chinese Children’s Cancer Group, including 79 diagnosed with TLS. The clinical characteristics, treatment regimens, and survival of TLS patients were analyzed. Age distribution of children with TLS was remarkably different from those without TLS. White blood cells (WBC) count ≥ 50 × 10⁹/L was associated with a higher risk of TLS [odds ratio (OR) = 2.6, 95% CI = 1.6–4.5]. The incidence of T-ALL in TLS children was significantly higher than that in non-TLS controls (OR = 4.7, 95% CI = 2.6–8.8). Hyperphosphatemia and hypocalcemia were more common in TLS children with hyperleukocytosis (OR = 2.6, 95% CI = 1.0–6.9 and OR = 5.4, 95% CI = 2.0–14.2, respectively). Significant differences in levels of potassium (P = 0.004), calcium (P < 0.001), phosphorus (P < 0.001) and uric acid (P < 0.001) were observed between groups of TLS patients with and without increased creatinine. Laboratory analysis showed that older age was associated with a higher level of creatinine. Calcium level was notably lower in males. WBC count, lactate dehydrogenase, and creatinine levels were significantly higher in T-ALL subgroup, whereas procalcitonin level was higher in B-ALL children. Older age, infant, a higher level of WBC and T-ALL were risk factors TLS occurrence. Hyperleukocytosis has an impact on the severity of TLS, while renal injury may be an important feature in the process of TLS.

Onconephrology: The intersections between the kidney and cancer

Onconephrology is a new subspecialty of nephrology that recognizes the important intersections of kidney disease with cancer. This intersection takes many forms and includes drug-induced nephrotoxicity, electrolyte disorders, paraneoplastic glomerulonephritis, and the interactions of chronic kidney disease with cancer. Data clearly demonstrate that, when patients with cancer develop acute or chronic kidney disease, outcomes are inferior, and the promise of curative therapeutic regimens is lessened. This highlights the imperative for collaborative care between oncologists and nephrologists in recognizing and treating kidney disease in patients with cancer. In response to this need, specific training programs in onconephrology as well as dedicated onconephrology clinics have appeared. This comprehensive review covers many of the critical topics in onconephrology, with a focus on acute kidney injury, chronic kidney disease, drug-induced nephrotoxicity, kidney disease in stem cell transplantation, and electrolyte disorders in patients with cancer.

Tumor lysis syndrome in chronic lymphocytic leukemia: conventional treatment versus novel agents: A protocol for systematic review and meta-analysis

Introduction:

Existing evidence on the difference in the incidence of tumor lysis syndrome (TLS) in Chronic Lymphocytic Leukemia (CLL) patients receiving novel therapies versus patients receiving conventional therapies is limited and inconclusive. The aims of this planned systematic review and meta-analysis are therefore

Methods:

We will conduct a systematic review and meta-analysis. Several electronic databases will be searched using predefined search terms to identify relevant studies. Eligible studies should report findings on the incidence of TLS in CLL patients. Primary observational studies with cross-sectional or prospective research design, case-control studies, and studies with experimental designs will be included. Study quality will be evaluated by 2 reviewers using the statistical methodology and categories described in the Cochrane Collaboration Handbook and preferred reporting items for systematic reviews and meta-analyses and other applicable guidelines. The meta-analysis will be performed and conducted using applicable standard statistical software like comprehensive meta-analysis and STATA.

Discussion:

This review and meta-analysis will be among the first to systematically explore and integrate the evidence available on the comparison between the incidences of TLS in CLL patients treated with novel agents versus conventional agents. By gathering and summarizing information about the risk of TLS in this patient population, the findings from this review will provide insights for future research directions and more understanding of the difference of TLS incidence between novel treatments and conventional treatment and suggest prophylactic measures for such cases.

Systematic review registration:

The protocol has been registered at the International Prospective Register of Systematic Reviews (PROSPERO; registration number: CRD42020166770).

The protocol was registered with the Hamad medical corporation, Medical research Center registry under a unique reference number (MRC-01-20-709).

Oncologic Emergencies: Traditional and Contemporary

The recognition and management of oncologic emergencies are becoming increasingly relevant in the intensive care unit, particularly in the era of novel biologic therapies. Early recognition and multidisciplinary collaboration are essential to improving patient outcomes. This article discusses aspects of diagnosis and management for important malignancy-associated emergencies.

Acute pneumothorax due to immunotherapy administration in non-small cell lung cancer

Nowadays we have novel therapies for advanced stage non-small cell lung cancer. Immunotherapy has been introduced in the market for several years and until now its administration is mostly based on the programmed death-ligand 1. First line treatment with immunotherapy can be administered alone if programmed death-ligand 1 expression is ≥ 50%. All therapies for advanced stage disease have advantages and disadvantages, immunotherapy until now has presented mild adverse effects when compared to chemotherapy. However; it is known to induce inflammatory response to different tissues within the body. In our case acute pneumothorax was induced after immunotherapy administration.

Determining the Significant Prognostic Factors for the Recurrence of Pediatric Acute Lymphoblastic Leukemia Using a Competing Risks Approach

Acute lymphoblastic leukemia (ALL) is the most common cause of cancer-related fatality among children. This study aimed to identify the significant prognostic factors for the incidence of pediatric ALL. This retrospective study, conducted from 2007 to 2016 in the Iranian city of Mashhad, enrolled 417 patients with ALL. The diagnosis was confirmed by Giemsa staining of bone marrow smears. The first recurrence was regarded as the event of interest and non-relapse mortality as the competing event through a three-parameter Gompertz model. The level of statistical significance for univariate and multivariate analyses was set at 0.2 and 0.05, respectively. The first recurrence occurred in 44 (10.6%) survivors. Disease-free survival and 5-year overall survival rates were 85.9% and 74%, correspondingly. The five-year incidence rate for the first recurrence was 11.5% in the presence of non-relapse mortality. Briefly, the characteristics of the Gompertz model conferred more effective prognostic factors. Age above 10 years (P=0.010), involvement of the central nervous system (P=0.050), a high white blood cell count (P=0.020), and tumor lysis syndrome (P=0.010) were the significant prognostic factors for the recurrence and mortality of ALL. Accordingly, careful monitoring in the administration of treatment protocols is suggested to reduce the risk of recurrence and death in these patients.

A provider's guide to primary myelofibrosis: pathophysiology, diagnosis, and management

Although understanding of the pathogenesis and molecular biology of primary myelofibrosis continues to improve, treatment options are limited, and several biological features remain unexplained. With an appropriate clinical history, exam, laboratory evaluation, and bone marrow biopsy, the diagnosis can often be established. Recent studies have better characterized prognostic factors and driver mutations in myelofibrosis, facilitated by use of next-generation sequencing. These advances have facilitated development of a management strategy that is based on both risk factors and clinical phenotype. For low-risk patients, treatment will depend on symptom severity. For patients with higher-risk disease, several treatments are available including JAK inhibitors, allogeneic hematopoietic stem cell transplant, and clinical trials using novel molecularly targeted therapies and rational drug combinations. In this review, we outline what is known about the disease pathogenesis, discuss an approach to reaching the diagnosis, review the prognosis of myelofibrosis, and detail current therapeutic strategies.

Emergency Department Management of Acute Kidney Injury, Electrolyte Abnormalities, and Renal Replacement Therapy in the Critically Ill

Acute kidney injury (AKI) is a common sequela of critical illness. Clinical manifestation of AKI varies and can include electrolyte abnormalities, anion gap, or non-anion-gap metabolic acidosis. Treatment strategies require careful identification of the cause of the AKI, relying on both clinical history and laboratory data. Once the cause has been identified, treatment can then target the underlying cause and avoid further insults. Conservative management should first be attempted for patients with AKI. If conservative management fails, renal replacement therapy or hemodialysis can be used.

Fluid Management in Acute Kidney Injury

Correction of intravascular hypovolemia is a key component of the prevention and management of acute kidney injury (AKI), but excessive fluid administration is associated with poor outcomes, including the development and progression of AKI. There is growing evidence that fluid administration should be individualized and take into account patient characteristics, nature of the acute illness and trajectories, and risks and benefits of fluids. Existing data support the preferential use of buffered solutions for fluid resuscitation of patients at risk of AKI who do not have hypochloremia. There is a limited role for albumin, and starches should be avoided. Fluids should only be administered until intravascular hypovolemia has been corrected and euvolemia has been achieved using the minimum amount of fluid required to achieve and maintain euvolemia. Oliguria alone should not be viewed as a trigger for fluid administration. If fluid overload occurs, fluid therapy needs to be discontinued, and fluid removal using diuretic agents or extracorporeal therapies should be considered.

Update on the prevention and treatment of tumor lysis syndrome

Tumor lysis syndrome is a constellation of metabolic derangements seen when tumor cells die and release their intracellular contents into the systemic circulation. Hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia may lead to severe organ dysfunction and even death. Tumor lysis syndrome is classically considered a complication of successful cancer treatment, but it can also occur in untreated malignancies characterized by rapid proliferation. In this review, we cover the types of cancers and chemo- and immunotherapies associated with tumor lysis syndrome, the mechanisms by which severe metabolic derangements can develop, and the available treatments.

A Critical Evaluation of Safety Signal Analysis Using Algorithmic Standardised MedDRA Queries

INTRODUCTION

Algorithmic Standardised MedDRA^® Queries (aSMQs) are increasingly used to enhance the efficiency of safety signal detection. The manner that aSMQs affect capture of potential safety cases is unclear.

OBJECTIVES

Our objective was to characterise the performance of aSMQs with respect to their potential for double counting, the likelihood of events in aSMQ positive cases being clinically related, how frequently terms are used for algorithmically positive cases, and the face validity of positive cases based on the drug inducing events. We were also interested in what effect requiring symptoms to overlap temporally would have on performance.

METHODS

We reviewed adverse event (AE) datasets of New Drug Applications and Biological License Applications and compiled a database including preferred terms and corresponding SMQs, SMQ term categories, AE start day, AE duration, drug name, and Anatomical Therapeutic Chemical class. Two reviewers independently determined if the algorithm was met and, if so, whether the broad terms overlapped temporally.

RESULTS

A total of 107 marketing applications were reviewed, including 103,928 patients and 277,430 AEs. Use of algorithms condensed the number of AEs to between 5 and 8% and the incidence to about 1.5% relative to when the SMQs are used without the algorithm. Certain aSMQs exhibited a potential for overcounting. Requiring symptoms to temporally overlap helped to eliminate irrelevant cases.

CONCLUSIONS

Our findings demonstrate that algorithmic and temporal assessment increased specificity of case retrieval, though the reduction in the number of terms or incidence seemed excessive for certain aSMQs. Evaluating the day of AE onset and duration improve specificity through identification of outlying events. Identification of drug classes known to cause the aSMQ's clinical condition provides face validity for this tool, yet detection of cases associated with novel classes may provide new understanding of these disorders. Improvements in some of the SMQ term lists may improve the performance of SMQs in general.

U-Shaped Association Between Serum Uric Acid Level and Risk of Mortality: A Cohort Study

OBJECTIVE

In addition to the controversy regarding the association of hyperuricemia with cardiovascular disease (CVD) mortality, few studies have examined the impact of a low uric acid level on mortality. We undertook the present study to evaluate the relationship between both low and high uric acid levels and the risk of all-cause and cause-specific mortality in a large sample of Korean adults over a full range of uric acid levels.

METHODS

A cohort study was performed in 375,163 South Korean men and women who underwent health check-ups from 2002 to 2012. Vital status and cause of death were ascertained from the national death records. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) for mortality outcomes were estimated using Cox proportional hazards regression analysis.

RESULTS

During a total of 2,060,721.9 person-years of follow-up, 2,020 participants died, with 287 CVD deaths and 963 cancer deaths. Low and high uric acid levels were associated with increased all-cause, CVD, and cancer mortality. The multivariable-adjusted HRs for all-cause mortality in the lowest uric acid categories (<3.5 mg/dl for men and <2.5 mg/dl for women) compared with the sex-specific reference category were 1.58 (95% CI 1.18-2.10) and 1.80 (95% CI 1.10-2.93), respectively. Corresponding HRs in the highest uric acid categories (≥9.5 mg/dl for men and ≥8.5 mg/dl for women) were 2.39 (95% CI 1.57-3.66) and 3.77 (95% CI 1.17-12.17), respectively.

CONCLUSION

In this large cohort study of men and women, both low and high uric acid levels were predictive of increased mortality, supporting a U-shaped association between serum uric acid levels and adverse health outcomes.