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Arthritis Research & Therapy
Published in: Arthritis Research & Therapy 4/2009

Open Access 01-08-2009 | Research article

Uric acid is a strong independent predictor of renal dysfunction in patients with rheumatoid arthritis

Authors: Dimitrios Daoussis, Vasileios Panoulas, Tracey Toms, Holly John, Ioannis Antonopoulos, Peter Nightingale, Karen MJ Douglas, Rainer Klocke, George D Kitas

Published in: Arthritis Research & Therapy | Issue 4/2009

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Abstract

Introduction

Recent evidence suggests that uric acid (UA), regardless of crystal deposition, may play a direct pathogenic role in renal disease. We have shown that UA is an independent predictor of hypertension and cardiovascular disease (CVD), and that CVD risk factors associate with renal dysfunction, in patients with rheumatoid arthritis (RA). In this study we investigated whether UA associates with renal dysfunction in patients with RA and whether such an association is independent or mediated through other comorbidities or risk factors for renal impairment.

Methods

Renal function was assessed in 350 consecutive RA patients by estimated glomerular filtration rate (GFR) using the six-variable Modification of Diet in Renal Disease equation. Risk factors for renal dysfunction were recorded or measured in all participants. Linear regression was used to test the independence of the association between GFR and UA.

Results

Univariable analysis revealed significant associations between GFR and age, systolic blood pressure, total cholesterol, triglycerides, RA duration and UA. UA had the most powerful association with renal dysfunction (r = -0.45, P < 0.001). A basic model was created, incorporating all of the above parameters along with body mass index and gender. UA ranked as the first correlate of GFR (P < 0.001) followed by age. Adjustments for the use of medications (diuretics, low-dose aspirin, cyclooxygenase II inhibitors and nonsteroidal anti-inflammatory drugs) and further adjustment for markers of inflammation and insulin resistance did not change the results.

Conclusions

UA is a strong correlate of renal dysfunction in RA patients. Further studies are needed to address the exact causes and clinical implications of this new finding. RA patients with elevated UA may require screening for renal dysfunction and appropriate management.
Appendix
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Literature
1.
2.
Nordin H, Pedersen LM: [Kidney function problems in rheumatoid arthritis]. Ugeskr Laeger. 1996, 158: 3137-3140.PubMed
3.
Pathan E, Joshi VR: Rheumatoid arthritis and the kidney. J Assoc Physicians India. 2004, 52: 488-494.PubMed
4.
Johnson RJ, Kang DH, Feig D, Kivlighn S, Kanellis J, Watanabe S, Tuttle KR, Rodriguez-Iturbe B, Herrera-Acosta J, Mazzali M: Is there a pathogenetic role for uric acid in hypertension and cardiovascular and renal disease?. Hypertension. 2003, 41: 1183-1190. 10.1161/01.HYP.0000069700.62727.C5.CrossRefPubMed
5.
Nakagawa T, Kang DH, Feig D, Sanchez-Lozada LG, Srinivas TR, Sautin Y, Ejaz AA, Segal M, Johnson RJ: Unearthing uric acid: an ancient factor with recently found significance in renal and cardiovascular disease. Kidney Int. 2006, 69: 1722-1725. 10.1038/sj.ki.5000391.CrossRefPubMed
6.
Ames BN, Cathcart R, Schwiers E, Hochstein P: Uric acid provides an antioxidant defense in humans against oxidant- and radical-caused aging and cancer: a hypothesis. Proc Natl Acad Sci USA. 1981, 78: 6858-6862. 10.1073/pnas.78.11.6858.PubMedCentralCrossRefPubMed
7.
Kanellis J, Feig DI, Johnson RJ: Does asymptomatic hyperuricaemia contribute to the development of renal and cardiovascular disease? An old controversy renewed. Nephrology (Carlton). 2004, 9: 394-399. 10.1111/j.1440-1797.2004.00336.x.CrossRef
8.
Feig DI, Rodriguez-Iturbe B, Nakagawa T, Johnson RJ: Nephron number, uric acid, and renal microvascular disease in the pathogenesis of essential hypertension. Hypertension. 2006, 48: 25-26. 10.1161/01.HYP.0000223447.53155.d5.CrossRefPubMed
9.
Khosla UM, Zharikov S, Finch JL, Nakagawa T, Roncal C, Mu W, Krotova K, Block ER, Prabhakar S, Johnson RJ: Hyperuricemia induces endothelial dysfunction. Kidney Int. 2005, 67: 1739-1742. 10.1111/j.1523-1755.2005.00273.x.CrossRefPubMed
10.
Sanchez-Lozada LG, Tapia E, Avila-Casado C, Soto V, Franco M, Santamaria J, Nakagawa T, Rodriguez-Iturbe B, Johnson RJ, Herrera-Acosta J: Mild hyperuricemia induces glomerular hypertension in normal rats. Am J Physiol Renal Physiol. 2002, 283: F1105-F1110.CrossRefPubMed
11.
Johnson RJ, Segal MS, Srinivas T, Ejaz A, Mu W, Roncal C, Sanchez-Lozada LG, Gersch M, Rodriguez-Iturbe B, Kang DH, Acosta JH: Essential hypertension, progressive renal disease, and uric acid: a pathogenetic link?. J Am Soc Nephrol. 2005, 16: 1909-1919. 10.1681/ASN.2005010063.CrossRefPubMed
12.
Sanchez-Lozada LG, Tapia E, Santamaria J, Avila-Casado C, Soto V, Nepomuceno T, Rodriguez-Iturbe B, Johnson RJ, Herrera-Acosta J: Mild hyperuricemia induces vasoconstriction and maintains glomerular hypertension in normal and remnant kidney rats. Kidney Int. 2005, 67: 237-247. 10.1111/j.1523-1755.2005.00074.x.CrossRefPubMed
13.
Kang DH, Nakagawa T, Feng L, Watanabe S, Han L, Mazzali M, Truong L, Harris R, Johnson RJ: A role for uric acid in the progression of renal disease. J Am Soc Nephrol. 2002, 13: 2888-2897. 10.1097/01.ASN.0000034910.58454.FD.CrossRefPubMed
14.
Obermayr RP, Temml C, Gutjahr G, Knechtelsdorfer M, Oberbauer R, Klauser-Braun R: Elevated uric acid increases the risk for kidney disease. J Am Soc Nephrol. 2008, 19: 2407-2413. 10.1681/ASN.2008010080.PubMedCentralCrossRefPubMed
15.
Weiner DE, Tighiouart H, Elsayed EF, Griffith JL, Salem DN, Levey AS: Uric acid and incident kidney disease in the community. J Am Soc Nephrol. 2008, 19: 1204-1211. 10.1681/ASN.2007101075.PubMedCentralCrossRefPubMed
16.
Chonchol M, Shlipak MG, Katz R, Sarnak MJ, Newman AB, Siscovick DS, Kestenbaum B, Carney JK, Fried LF: Relationship of uric acid with progression of kidney disease. Am J Kidney Dis. 2007, 50: 239-247. 10.1053/j.ajkd.2007.05.013.CrossRefPubMed
17.
Hsu CY, Iribarren C, McCulloch CE, Darbinian J, Go AS: Risk factors for end-stage renal disease: 25-year follow-up. Arch Intern Med. 2009, 169: 342-350. 10.1001/archinternmed.2008.605.PubMedCentralCrossRefPubMed
18.
Avram Z, Krishnan E: Hyperuricaemia – where nephrology meets rheumatology. Rheumatology (Oxford). 2008, 47: 960-964. 10.1093/rheumatology/ken070.CrossRef
19.
Panoulas VF, Douglas KM, Milionis HJ, Nightingale P, Kita MD, Klocke R, Metsios GS, Stavropoulos-Kalinoglou A, Elisaf MS, Kitas GD: Serum uric acid is independently associated with hypertension in patients with rheumatoid arthritis. J Hum Hypertens. 2008, 22: 177-182. 10.1038/sj.jhh.1002298.CrossRefPubMed
20.
Panoulas VF, Milionis HJ, Douglas KM, Nightingale P, Kita MD, Klocke R, Elisaf MS, Kitas GD: Association of serum uric acid with cardiovascular disease in rheumatoid arthritis. Rheumatology (Oxford). 2007, 46: 1466-1470. 10.1093/rheumatology/kem159.CrossRef
21.
Daoussis D, Panoulas VF, Antonopoulos , John H, Toms TE, Wong P, Nightingale P, Douglas KM, Kitas GD: Cardiovascular risk factors and not disease activity, severity or therapy associate with renal dysfunction in patients with rheumatoid arthritis. Ann Rheum Dis. 2009.
22.
Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, Healey LA, Kaplan SR, Liang MH, Luthra HS: The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum. 1988, 31: T315-324. 10.1002/art.1780310302.CrossRef
23.
Prevoo ML, 't Hof MA, Kuper HH, van Leeuwen MA, Putte van de LB, van Riel PL: Modified disease activity scores that include twenty-eight-joint counts. Development and validation in a prospective longitudinal study of patients with rheumatoid arthritis. Arthritis Rheum. 1995, 38: 44-48. 10.1002/art.1780380107.CrossRefPubMed
24.
Kirwan JR, Reeback JS: Stanford Health Assessment Questionnaire modified to assess disability in British patients with rheumatoid arthritis. Br J Rheumatol. 1986, 25: 206-209. 10.1093/rheumatology/25.2.206.CrossRefPubMed
25.
Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D: A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med. 1999, 130: 461-470.CrossRefPubMed
26.
27.
Cockcroft DW, Gault MH: Prediction of creatinine clearance from serum creatinine. Nephron. 1976, 16: 31-41. 10.1159/000180580.CrossRefPubMed
28.
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, Jones DW, Materson BJ, Oparil S, Wright JT, Roccella EJ: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003, 289: 2560-2572. 10.1001/jama.289.19.2560.CrossRefPubMed
29.
Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 1997, 20: 1183-1197.
30.
Matthews DR, Hosker JP, Rudenski AS, Naylor BA, Treacher DF, Turner RC: Homeostasis model assessment: insulin resistance and beta-cell function from fasting plasma glucose and insulin concentrations in man. Diabetologia. 1985, 28: 412-419. 10.1007/BF00280883.CrossRefPubMed
31.
Katz A, Nambi SS, Mather K, Baron AD, Follmann DA, Sullivan G, Quon MJ: Quantitative insulin sensitivity check index: a simple, accurate method for assessing insulin sensitivity in humans. J Clin Endocrinol Metab. 2000, 85: 2402-2410. 10.1210/jc.85.7.2402.CrossRefPubMed
32.
Richardson J: How to measure renal function in clinical practice: estimated glomerular filtration rate in general practice. BMJ. 2006, 333: 918-10.1136/bmj.333.7574.918-a.PubMedCentralCrossRefPubMed
33.
Anders HJ, Rihl M, Loch O, Schattenkirchner M: Prediction of creatinine clearance from serum creatinine in patients with rheumatoid arthritis: comparison of six formulae and one nomogram. Clin Rheumatol. 2000, 19: 26-29. 10.1007/s100670050006.CrossRefPubMed
34.
Boers M, Dijkmans BA, Breedveld FC: Prediction of glomerular filtration rate in patients with rheumatoid arthritis: satisfactory performance of Cockroft formula. J Rheumatol. 1994, 21: 581-582.PubMed
35.
Vaziri ND, Freel RW, Hatch M: Effect of chronic experimental renal insufficiency on urate metabolism. J Am Soc Nephrol. 1995, 6: 1313-1317.PubMed
36.
Mazzali M, Kanellis J, Han L, Feng L, Xia YY, Chen Q, Kang DH, Gordon KL, Watanabe S, Nakagawa T, Lan HY, Johnson RJ: Hyperuricemia induces a primary renal arteriolopathy in rats by a blood pressure-independent mechanism. Am J Physiol Renal Physiol. 2002, 282: F991-F997.CrossRefPubMed
37.
Nakagawa T, Mazzali M, Kang DH, Kanellis J, Watanabe S, Sanchez-Lozada LG, Rodriguez-Iturbe B, Herrera-Acosta J, Johnson RJ: Hyperuricemia causes glomerular hypertrophy in the rat. Am J Nephrol. 2003, 23: 2-7. 10.1159/000066303.CrossRefPubMed
38.
Watanabe S, Kang DH, Feng L, Nakagawa T, Kanellis J, Lan H, Mazzali M, Johnson RJ: Uric acid, hominoid evolution, and the pathogenesis of salt-sensitivity. Hypertension. 2002, 40: 355-360. 10.1161/01.HYP.0000028589.66335.AA.CrossRefPubMed
39.
Iseki K, Oshiro S, Tozawa M, Iseki C, Ikemiya Y, Takishita S: Significance of hyperuricemia on the early detection of renal failure in a cohort of screened subjects. Hypertens Res. 2001, 24: 691-697. 10.1291/hypres.24.691.CrossRefPubMed
40.
Domrongkitchaiporn S, Sritara P, Kitiyakara C, Stitchantrakul W, Krittaphol V, Lolekha P, Cheepudomwit S, Yipintsoi T: Risk factors for development of decreased kidney function in a southeast Asian population: a 12-year cohort study. J Am Soc Nephrol. 2005, 16: 791-799. 10.1681/ASN.2004030208.CrossRefPubMed
41.
Siu YP, Leung KT, Tong MK, Kwan TH: Use of allopurinol in slowing the progression of renal disease through its ability to lower serum uric acid level. Am J Kidney Dis. 2006, 47: 51-59. 10.1053/j.ajkd.2005.10.006.CrossRefPubMed
42.
Talaat KM, el Sheikh AR: The effect of mild hyperuricemia on urinary transforming growth factor beta and the progression of chronic kidney disease. Am J Nephrol. 2007, 27: 435-440. 10.1159/000105142.CrossRefPubMed
43.
Kitas GD, Erb N: Tackling ischaemic heart disease in rheumatoid arthritis. Rheumatology (Oxford). 2003, 42: 607-613. 10.1093/rheumatology/keg175.CrossRef
44.
Dessein PH, Joffe BI, Stanwix AE: Inflammation, insulin resistance, and aberrant lipid metabolism as cardiovascular risk factors in rheumatoid arthritis. J Rheumatol. 2003, 30: 1403-1405.PubMed
45.
Tsouli SG, Liberopoulos EN, Mikhailidis DP, Athyros VG, Elisaf MS: Elevated serum uric acid levels in metabolic syndrome: an active component or an innocent bystander?. Metabolism. 2006, 55: 1293-1301. 10.1016/j.metabol.2006.05.013.CrossRefPubMed
46.
Gagliardi AC, Miname MH, Santos RD: Uric acid: a marker of increased cardiovascular risk. Atherosclerosis. 2009, 202: 11-17. 10.1016/j.atherosclerosis.2008.05.022.CrossRefPubMed
47.
Goldberg RJ, Burchfiel CM, Benfante R, Chiu D, Reed DM, Yano K: Lifestyle and biologic factors associated with atherosclerotic disease in middle-aged men. 20-year findings from the Honolulu Heart Program. Arch Intern Med. 1995, 155: 686-694. 10.1001/archinte.155.7.686.CrossRefPubMed
48.
Fang J, Alderman MH: Serum uric acid and cardiovascular mortality the NHANES I epidemiologic follow-up study, 1971–1992. National Health and Nutrition Examination Survey. JAMA. 2000, 283: 2404-2410. 10.1001/jama.283.18.2404.CrossRefPubMed
49.
Alderman MH, Cohen H, Madhavan S, Kivlighn S: Serum uric acid and cardiovascular events in successfully treated hypertensive patients. Hypertension. 1999, 34: 144-150.CrossRefPubMed
50.
Verdecchia P, Schillaci G, Reboldi G, Santeusanio F, Porcellati C, Brunetti P: Relation between serum uric acid and risk of cardiovascular disease in essential hypertension. The PIUMA study. Hypertension. 2000, 36: 1072-1078.CrossRefPubMed
51.
Bickel C, Rupprecht HJ, Blankenberg S, Rippin G, Hafner G, Daunhauer A, Hofmann KP, Meyer J: Serum uric acid as an independent predictor of mortality in patients with angiographically proven coronary artery disease. Am J Cardiol. 2002, 89: 12-17. 10.1016/S0002-9149(01)02155-5.CrossRefPubMed
52.
Mazzali M, Hughes J, Kim YG, Jefferson JA, Kang DH, Gordon KL, Lan HY, Kivlighn S, Johnson RJ: Elevated uric acid increases blood pressure in the rat by a novel crystal-independent mechanism. Hypertension. 2001, 38: 1101-1106. 10.1161/hy1101.092839.CrossRefPubMed
53.
Alper AB, Chen W, Yau L, Srinivasan SR, Berenson GS, Hamm LL: Childhood uric acid predicts adult blood pressure: the Bogalusa Heart Study. Hypertension. 2005, 45: 34-38.CrossRefPubMed
54.
Feig DI: Uric acid and hypertension in adolescents. Semin Nephrol. 2005, 25: 32-38. 10.1016/j.semnephrol.2004.09.006.CrossRefPubMed
55.
McEntegart A, Capell HA, Creran D, Rumley A, Woodward M, Lowe GD: Cardiovascular risk factors, including thrombotic variables, in a population with rheumatoid arthritis. Rheumatology (Oxford). 2001, 40: 640-644. 10.1093/rheumatology/40.6.640.CrossRef
56.
Erb N, Pace AV, Douglas KM, Banks MJ, Kitas GD: Risk assessment for coronary heart disease in rheumatoid arthritis and osteoarthritis. Scand J Rheumatol. 2004, 33: 293-299. 10.1080/03009740410006899.CrossRefPubMed
57.
Doehner W, Schoene N, Rauchhaus M, Leyva-Leon F, Pavitt DV, Reaveley DA, Schuler G, Coats AJ, Anker SD, Hambrecht R: Effects of xanthine oxidase inhibition with allopurinol on endothelial function and peripheral blood flow in hyperuricemic patients with chronic heart failure: results from 2 placebo-controlled studies. Circulation. 2002, 105: 2619-2624. 10.1161/01.CIR.0000017502.58595.ED.CrossRefPubMed
58.
Doehner W, Anker SD: Xanthine oxidase inhibition for chronic heart failure: is allopurinol the next therapeutic advance in heart failure?. Heart. 2005, 91: 707-709. 10.1136/hrt.2004.057190.PubMedCentralCrossRefPubMed
59.
Bacon PA, Stevens RJ, Carruthers DM, Young SP, Kitas GD: Accelerated atherogenesis in autoimmune rheumatic diseases. Autoimmun Rev. 2002, 1: 338-347. 10.1016/S1568-9972(02)00100-3.CrossRefPubMed
60.
Muscelli E, Natali A, Bianchi S, Bigazzi R, Galvan AQ, Sironi AM, Frascerra S, Ciociaro D, Ferrannini E: Effect of insulin on renal sodium and uric acid handling in essential hypertension. Am J Hypertens. 1996, 9: 746-752. 10.1016/0895-7061(96)00098-2.CrossRefPubMed
61.
Fliser D, Pacini G, Engelleiter R, Kautzky-Willer A, Prager R, Franek E, Ritz E: Insulin resistance and hyperinsulinemia are already present in patients with incipient renal disease. Kidney Int. 1998, 53: 1343-1347. 10.1046/j.1523-1755.1998.00898.x.CrossRefPubMed
62.
Kubo M, Kiyohara Y, Kato I, Iwamoto H, Nakayama K, Hirakata H, Fujishima M: Effect of hyperinsulinemia on renal function in a general Japanese population: the Hisayama study. Kidney Int. 1999, 55: 2450-2456. 10.1046/j.1523-1755.1999.00458.x.CrossRefPubMed
63.
Kato Y, Hayashi M, Ohno Y, Suzawa T, Sasaki T, Saruta T: Mild renal dysfunction is associated with insulin resistance in chronic glomerulonephritis. Clin Nephrol. 2000, 54: 366-373.PubMed
64.
Chen J, Muntner P, Hamm LL, Fonseca V, Batuman V, Whelton PK, He J: Insulin resistance and risk of chronic kidney disease in nondiabetic US adults. J Am Soc Nephrol. 2003, 14: 469-477. 10.1097/01.ASN.0000046029.53933.09.CrossRefPubMed
65.
Peralta CA, Ziv E, Katz R, Reiner A, Burchard EG, Fried L, Kwok PY, Psaty B, Shlipak M: African ancestry, socioeconomic status, and kidney function in elderly African Americans: a genetic admixture analysis. J Am Soc Nephrol. 2006, 17: 3491-3496. 10.1681/ASN.2006050493.CrossRefPubMed
66.
Metadata
Title
Uric acid is a strong independent predictor of renal dysfunction in patients with rheumatoid arthritis
Authors
Dimitrios Daoussis
Vasileios Panoulas
Tracey Toms
Holly John
Ioannis Antonopoulos
Peter Nightingale
Karen MJ Douglas
Rainer Klocke
George D Kitas
Publication date
01-08-2009
Publisher
BioMed Central
Published in
Arthritis Research & Therapy / Issue 4/2009
Electronic ISSN: 1478-6362
DOI
https://doi.org/10.1186/ar2775

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