Skip to content

Advertisement

You're viewing the new version of our site. Please leave us feedback.

Learn more

BMC Nephrology

Open Access
Open Peer Review

This article has Open Peer Review reports available.

How does Open Peer Review work?

Hyperuricemia increases the risk of acute kidney injury: a systematic review and meta-analysis

BMC NephrologyBMC series – open, inclusive and trusted201718:27

https://doi.org/10.1186/s12882-016-0433-1

Received: 23 October 2016

Accepted: 21 December 2016

Published: 17 January 2017

Abstract

Background

Mounting evidence indicated that the elevated serum uric acid level was associated with an increased risk of acute kidney injury (AKI). Our goal was to systematically evaluate the correlation of serum uric acid (SUA) level and incidence of AKI by longitudinal cohort studies.

Methods

We searched electronic databases and the reference lists of relevant articles. 18 cohort studies with 75,200 patients were analyzed in this random-effect meta-analysis. Hyperuricemia was defined as SUA levels greater than 360-420 μmol/L (6–7 mg/dl), which was various according to different studies. Data including serum uric acid, serum creatinine, and incidence of AKI and hospital mortality were summarized using random-effects meta-analysis.

Results

The hyperuricemia group significantly exerted a higher risk of AKI compared to the controls (odds ratio OR 2.24, 95% CI 1.76-2.86, p < 0.01). Furthermore, there is less difference of the pooled rate of AKI after cardiac surgery between hyperuricemia and control group (34.3% vs 29.7%, OR 1.24, 95% CI 0.96-1.60, p = 0.10), while the rates after PCI were much higher in hyperuricemia group than that in control group (16.0% vs 5.3%, OR 3.24, 95% CI 1.93-5.45, p < 0.01). In addition, there were significant differences in baseline renal function at admission between hyperuricemia and control groups in most of the included studies. The relationship between hyperuricemia and hospital mortality was not significant. The pooled pre-operative SUA levels were higher in AKI group than that in the non-AKI group.

Conclusions

Elevated SUA level showed an increased risk for AKI in patients and measurements of SUA may help identify risks for AKI in these patients.

Keywords

Acute kidney injuryHyperuricemiaUric acidMeta-analysis

Background

Acute kidney injury (AKI) occurs commonly after cardiovascular surgery, in patients with sepsis, and after the administration of various nephrotoxins including contrast agents. The incidence of AKI has a significant effect on the outcomes. Prevention before any procedure is essential because no measures have been proven to effectively treat AKI. Therefore, if high-risk patients could be screened earlier, the clinician still would have opportunities to prevent AKI and further improve outcomes [1, 2].

Uric acid is an end-product of purine degradation and is excreted via kidney. Many epidemiologic studies have suggested that hyperuricemia is associated with hypertension, cardiovascular diseases, diabetes mellitus and the progression of chronic kidney disease [35]. In addition, it is found that hyperuricemia is associated with acute kidney injury (AKI) in various statuses [69]. This meta-analysis was conducted to estimate whether hyperuricemia is an independent risk factor for incidence and prognosis of AKI. This effort hoped to raise awareness of the importance of hyperuricemia in the developing AKI.

Methods

Search strategy and data sources

We performed a computerized search to identify relevant published original studies (1985 to May 2016). Pubmed, Web of Science, Cochrwane Library, OVID and EMBASE databases were searched using medical subject headings (MeSH) or keywords. These words were “acute kidney failure, acute kidney injury, acute kidney dysfunction, acute kidney insufficiency, acute tubular necrosis, acute renal failure, acute renal injury, acute renal dysfunction, or acute renal insufficiency” and “hyperuricemia, or uric acid”. This search was not limited to English language or publication type. We followed a prespecified protocol but this was not registered.

Selection criteria

An initial eligibility screen of all retrieved titles and abstracts was performed, and only studies reporting the relationship between serum uric acid (SUA) and AKI were selected for further review. The following included criteria were used for final selection: (1) studies reporting the incidence of AKI and pre-operative SUA Levels, (2) studies using clear definition of AKI, and hyperuricemia, (3) studies providing detailed information about the incidence of AKI, and/or hospital mortality. We restricted our search to clinical studies performed in adult populations. Studies without clear grouping or animal experimental studies were excluded.

Data extraction and quality assessment

Two reviewers (X.X.L and H.J.C) examined the studies independently, and disagreement was resolved by discussion. Data extraction included country of origin, year of publication, study period, study design, inclusion criteria, definition of hyperuricemia or grouping according to SUA, conclusions and patient characteristics (age and sex). Hyperuricemia was defined as SUA levels greater than 360-420 μmol/L (6–7 mg/dl), which was various according to different studies. The primary outcomes were odds ratio (OR) of SUA to predict incidence of AKI. The definition of AKI in all these included studied used the AKI network criteria [10] with minor modification and defined as an increase ≥0.3 mg/dL in the serum creatintine level within 48 h in the hospital or ICU (Table 1). The second outcomes included SUA levels in AKI and No-AKI group and hospital mortality in hyperuricemia and control group. The study selection, data extraction and reporting of results were all based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses checklist [11]. The quality of the cohort studies was assessed independently by pairs of two authors, using the Newcastle-Ottawa scale (NOS) [12], which allocates a maximum of 9 points for quality of the selection, comparability, and outcome of study populations. Study quality scores were defined as poor (0–3), fair (4–6), or good (7–9).
Table 1

Characteristics of studies included in the meta-analysis

Authors (year)

Study period

Country

Study design

Sample size

Mean age (y)

Percentage of Male (%)

Inclusion criteria

Definition of hyperuricemia or grouping according to SUA

Definition of AKI

Mean baseline eGFR in HUA group (ml/min/1.73 m2)

Conclusions

Shacham, et al. (2016) [48]

2008–2015

Israel

Retrospective cohort

1372

62 ± 12

85

Acute STEMI patients requiring PCI

<4.7 mg/dl, 4.8–5.6 mg/dl, 5.7–6.6 mg/dl, >6.7 mg/dl

A rise in sCr >0.3 mg/d above the admission sCr within 48 h

79 ± 19, 75 ± 17, 70 ± 11, 63 ± 20 for 4 groups respectively

Elevated UA levels are an independent predictor of AKI

Cheungpasitporn, et al. (2016) [49]

2011–2013

USA

Retrospective cohort

1435

62 ± 16

60.3

All hospitalized adult patients without ESRD and AKI at presentation and trauma

<3.4 mg/dl, 3.4–4.5 mg/dl, 4.5–5.8 mg/dl, 5.8–7.6 mg/dl, 7.6–9.4 mg/dl, >9 mg/dl

An increase in sCr ≥0.3 mg/dL within 48 h or ≥1.5 times baseline within 7 days after admission date

89.5 ± 20.6, 88.1 ± 21.9, 79.3 ± 24.5, 71.7 ± 24.8, 58.6 ± 22.3, 53.2 ± 21.8 for 6 groups respectively

Elevated admission SUA was associated with an increased risk for in-hospital AKI

Otomo, et al. (2015) [6]

1981–2011

Japan

Retrospective cohort

59,219

58.6 ± 17.9

48.4

All hospitalized patients

The first stratum: SUA ≤2.0 mg/dL; the 12th stratum: SUA >7.0 mg/dL, with SUA levels in each succeeding stratum increasing by increments of 0.5 mg/dL

An increase ≥0.3 mg/dL in the sCr level within 48 h; or ≥1.5 times baseline within the prior 7 days; or urine volume of 0.5 mL/kg/h within 6 h

102 ± 50, 99 ± 44, 96 ± 45, 93 ± 38, 88 ± 31, 86 ± 34, 81 ± 28, 79 ± 29, 76 ± 28, 73 ± 28, 70 ± 27, 59 ± 34 for 6 groups respectively

SUA level could be an independent risk factor for AKI development in hospitalized patients

Liang, et al. (2015) [50]

2009–2014

China

Prospective cohort

59

37.3 ± 10.6

NR

Severe burn

NR

An absolute anincrease in sCr > 0.3 mg/dl from baseline within 48 h after injury

NR

Elevated SUA after injury due to hypoxia is closely correlated with early AKI after severe burns

Lee, et al. (2015) [7]

2006–2011

Korea

Retrospective cohort

2,185

63.6 ± 9.1

74.7

All patients undergoing CABG

NR

An increase in sCr of ≥0.3 mg/dL or ≥150% from baseline within the first 48 h after operation

NR

Preoperatively Elevated SUA was significantly associated with AKI and improved the ability to predict the development of AKI in patients undergoing CABG

Lazzeri, et al. (2015) [51]

2006–2013

Italy

Prospective cohort

329

77.2 ± 10.0

53.8

STEMI patients submitted to primary PCI

SUA ≤ 5.9 mg/dl, 6.0–7.4 mg/dl, >7.4 mg/dl

An absolute increase in sCr level of 0.3 mg/dl or more, or a relative increase in sCr level of 50% or more during the ICCU stay

42.8 ± 14.3, 42.5 ± 13.4, 40.8 ± 12.2 for 3 groups respectively

Uric acid helps in identifying a subset of patients at a higher risk of AKI and 1-year mortality.

Gaipov, et al. (2015) [52]

2011–2012

Turkey

Prospective cohort

60

56.7 ± 16.4

70.0

Patients undergoing cardiac surgery

NR

An increase in sCr by 0.3 mg/dL within 48 h or increase in sCr to 1.5 times baseline

NR

Uric acid seems to predict the progression of AKI and RRT requirement in patients underwent cardiac surgery better than NGAL

Barbieri, et al. (2015) [8]

2007–2011

Italy

Retrospective cohort

1,950

72.1 ± 8.7

NR

Patients undergoing coronary angiography and /or angioplasty with GFR ≤ 89 ml/min

SUA ≤ 5.5 mg/dL; 5.6–7.0 mg/dL; ≥7.0 mg/dL

An absolute ≥0.5 mg/dl or a relative ≥25% increase in the sCr level at 24 or 48 h after the procedure

NR

Elevated SUA level is independently associated with an increased risk of CIN

Guo, et al. (2015) [53]

2010–2013

China

Prospective cohort

1772

64.43 ± 11.35

76.5

Patients who underwent PCI

SUA > 7 mg/dL (417 μmol/L) in males and >6 mg/dL (357 μmol/L) in females.

an increase in sCr of >0.5 mg/dL from the baseline within 48–72 h of contrast exposure

71.08 ± 24.70

Hyperuricemia is associated with a risk of CI-AKI. Long-term mortality after PCI was higher in those with hyperuricemia than with normouricemia after adjusting.

Joung, et al. (2014) [54]

2011–2012

Korea

Retrospective cohort

1,094

63.0

62.2

Patients undergoing cardiovascular surgery

SUA > 6.5 mg/dL (preoperative) (6.0 mg/dL in women and 7.0 mg/dL in men)

An increase ≥0.3 mg/dL in the sCr level or ≥1.5 times baseline within 48 h

NR

Preoperative elevated serum uric acid is an independent risk factor for AKI in patients undergoing cardiovascular surgery.

Xu, et al. (2014) [55]

2005–2011

China

Retrospective cohort

936

65.2 ± 4.2

54.3

Old patients (≥60 years) undergoing CPB

SUA ≤ 384.65; 384.66–476.99; ≥477.00 μmol/L (males) SUA ≤ 354.00; 354.01–437.96; ≥437.97 μmol/L (females)

An increase in sCr ≥150% from baseline within the first 7 days after operation

73.8 ± 17.2, 69.3 ± 14.2, 61.5 ± 15.8 for 3 groups respectively

Pre-operative elevated uric acid is an independent risk factor of AKI after cardiac surgery in elderly patients

Liu, et al. (2013) [56]

2010–2011

China

Prospective cohort

788

62.8 ± 11.3

78.6

Patients undergoing PCI

SUA >7 mg/dL in males and >6 mg/dL in females

An increase in sCr of ≥ 0.5 mg/dL above the baseline value within 48–72 h after PCI

*Creatinine Clearance: 65 ± 24 ml/min

Hyperuricemia was significantly associated with the risk of CI-AKI in patients with relatively normal serum creatinine after PCI

Lapsia, et al. (2012) [57]

2004–2008

USA

Retrospective cohort

190

63.9 ± 0.9

62.1

Patients undergoing cardiovascular surgery

SUA ≥7 mg/dL

An absolute increase in sCr of ≥ 0.3 mg/dL from baseline within 48 h after surgery

47.6 ± 1.8

Preoperative SUA was associated with increased incidence and risk for AKI

Ejaz, et al. (2012) [58]

NR

USA

Prospective cohort

100

61.4 ± 1.4

60

Patients undergoing cardiac surgery with eGFR > 30 ml/min/1.73 m2

SUA < 4.53 mg/dL, 4.53–5.77 mg/dL, > 5.77 mg/dL

An absolute increase in sCr ≥ 0.3 mg/dL from baseline within 48 h after surgery

NR

Post-operative SUA is associated with an increased risk for AKI and compares well to conventional markers of AKI

Park, et al. (2011) [59]

2006–2009

Korea

Retrospective cohort

1,247

64.3 ± 11.9

62.3

Patients undergoing PCI

SUA ≥7.0 mg/dl for males and ≥ 6.5 mg/dl for females.

An increase in sCr of ≥0.5 mg/dl or ≥50% over baseline within 7 days of PCI

NR

Hyperuricemia is independently associated with an increased risk of in-hospital mortality and AKI in patients treated with PCI

Kim, et al. (2011) [60]

2007–2008

Korea

Retrospective cohort

247

46.1 ± 13.7

52

Acute PQ intoxication

SUA ≥7.3 mg/dL in men or ≥5.3 mg/dL in women

An increase in sCr of ≥0.3 mg/dL or ≥150% from baseline within 48 h after admission

NR

Baseline serum uric acid level might be a good clinical marker for patients at risk of mortality and AKI after acute PQ intoxication

Ben-Dov, I. Z., et al. (2011) [61]

1976–1979

Israel

Retrospective cohort

2449

58.8

50 ± 6

Patients in Lipid Research Clinic cohort

>6.5 mg/dL in men and >5.3 mg/dL in women

NR

93 ± 18 in men and women

SUA was found to be a strong predictor of acute renal failure

Toprak et al. (2006) [62]

2004–2005

Turkey

Prospective cohort

266

58.9 ± 7.4

61%

Nonemergency diagnostic coronary angiography with Scr > 1.2 mg/dl

>7 mg/dl in men and 6.5 mg/dl in women.

An increase of ≥25% in sCr over baseline within 48 h of coronary angiography

55.26 ± 13.7

Patients with hyperuricemia are at risk of developing CIN.

Abbreviations: SUA serum uric acid, sCr serum creatintine, AKI acute kidney injury, CABG Coronary Artery Bypass Grafting, STEMI ST-elevation myocardial infarction, PCI percutaneous coronary intervention, NGAL neutrophil gelatinase-associated lipocalin, GFR glomerular filtration rate, eGFR estimated glomerular filtration rate, CIN contrast-induced nephropathy, CI-AKI contrast-induced acute kidney injury, PQ paraquat, NR not reported

Data synthesis and statistical analysis

Review Manager (RevMan, Cochrane Collaboration, version 5.3) and Comprehensive Meta-Analysis (CMA version 2.0, Biostat) were used to perform the meta-analysis. Pooled estimates were obtained for incidence of AKI and hospital mortality, which were reported using random-effects meta-analysis based on the methods of DerSimonian and Laird [13]. Meta-analyses were performed using OR for dichotomous outcomes. All confidence intervals (CI) were reported at 95%. P-value statistical significance was measured at 0.05. Heterogeneity across trials was evaluated with using theI 2 index and the Q test p value. A p value of less than 0.05 and anI 2 index of more than 25% indicated the presence of interstudy heterogeneity [14]. Publication bias was assessed by constructing a funnel plot and Egger’s regression test.

Results

Study selection

The article selection process is outlined in Fig. 1. The electronic database searches identified 1272 citations. After removal of duplicates and preliminary screening, 84 articles were selected for full-text review for their relevance to this study and 18 studies were included in this systematic review. At the full-text review stage, 30 articles were not about AKI, 18 did not involve hyperuricemia and 15 were review. Seven studies were excluded from the primary meta-analysis as they did not report the detailed information, and the corresponding authors were unable to provide the requisite data. Agreement between investigators at the full-text review stage was excellent as indicated by a κ of 0.8.
Fig. 1

Flow chart of literature search and study selection

Study description and quality assessment

A detailed description of the included studies is provided in Table 1. The included studies were published between 2006 and 2016, and were carried out in a wide range of countries. The total number of patients included in the primary meta-analysis was 75,200 with a median (interquartile range) of 559 (122–1774) patients per study. The detailed information of age and gender was also listed in Table 1. Overall study quality was good with a mean NOS score of 7.5 out of a possible 9 (range, 7–9) and with 11 studies (91.7%) receiving a NOS greater than or equal to 7 (Table 2).
Table 2

Quality of the studies utilizing the Newcastle-Ottawa quality assessment scale (Cohort studies)

Reference (Year)

Selection

Comparability

Outcome

Total score

Representativeness of exposed cohort

Selection of the non-exposed cohort

Ascertainment of exposure

Demonstration that outcome was not present at start of study

Comparability of cohorts onthe basis of the design or analysis

Assessment of outcome

Follow up long enough

Adequacy of follow up of cohorts

Shacham, et al. (2016)

9

Cheungpasitporn, et al. (2016)

9

Otomo, et al. (2015) [6]

9

Liang, et al. (2015)

-

-

6

Lee, et al. (2015) [7]

9

Lazzeri, et al. (2015)

-

-

6

Gaipov, et al. (2015)

-

-

6

Barbieri, et al. (2015) [8]

-

7

Guo, et al. (2015)

9

Joung, et al. (2014)

-

-

6

Xu, et al. (2014)

9

Liu, et al. (2013)

9

Lapsia, et al. (2012)

-

-

6

Ejaz, etal (2012) [43]

-

7

Park, et al. (2011)

-

-

6

Kim, et al. (2011)

9

Ben-Dov, I. Z., et al. (2011)

--

-

6

Toprakm, et al. (2006)

8

Effects of SUA on the incidence of AKI

Eleven observational studies with 70,264 patients reported the incidence of AKI. The pooled rates of AKI incidence in hyperuricemia group and control group were 24.2% (95% CI, 16.1-34.7%) and 11.9% (95% CI, 7.2-19.0%) respectively (OR 2.24, 95% CI 1.76-2.86, p < 0.00001) (Figs. 2a and 3). Four studies reported ORs of SUA to predict AKI by binary logistic regression and ten studies reported ORs by multiple logistic regression, and the pooled ORs were 1.864 (95% CI 0.890-3.904, p = 0.000) and 2.061 (95% CI 1.545-2.749, p = 0.000) respectively (Fig. 4).
Fig. 2

Hyperuricemia and acute kidney injury. a The pooled rates of AKI incidence in control and hyperuricemia (HUA) group; (b) Subgroup analysis in all hospitalized patients and patients with cardiac surgery and PCI; (c) The pooled hospital mortality in control and HUA group; (d) The pooled levels of SUA in No-AKI and AKI group. *p < 0.05, **p < 0.01

Fig. 3

Effects of hyperuricemia on incidence of acute kidney injury

Fig. 4

Pooled odds ratios of serum uric acid to predict acute kidney injury

Fig. 5

Effects of hyperuricemia on incidence of acute kidney injury in all and subgroup analysis

Fig. 6

Effects of hyperuricemia on incidence of acute kidney injury in prospective and retrospective studies

Subgroup analysis

Although the pooled rates of AKI incidence after cardiac surgery in hyperuricemia and control group were 34.3% (95% CI 4.4-85.5%) and 29.7% (95% CI 4.6-78.7%) respectively (OR 1.24, 95% CI 1.96-1.60, p = 0.10), the AKI incidence after percutaneous coronary intervention (PCI) were 16.0% (95% CI 8.6-27.7%) and 5.3% (95% CI 2.5-10.9%) respectively (OR 3.24, 95% CI 1.93-5.45, p < 0.00001) (Figs. 2b and 5).

We also conducted subgroup analysis of prospective and retrospective cohort studies (Fig. 6). The pooled ORs of hyperuricemia on AKI were 2.87 (95% CI 1.43-5.76) and 2.11 (95% CI 1.63-2.75) respectively. In addition, to reduce the bias of included patients, we also analyzed studies with or without equal renal function, which was defined as serum creatintine or estimated glomerular filtration rate (eGFR) without significant different at admission between hyperuricemia and control groups. There were significant differences in renal function at admission between hyperuricemia and control groups in most of the included studies, while only two studies with equal renal function were included, and the pooled OR was 3.21 (95% CI 1.22-8.44, p = 0.02) (Fig. 7).
Fig. 7

Effects of hyperuricemia on incidence of acute kidney injury in patients with or without equal renal function at admission

Effects of SUA on hospital mortality

Five studies with 3735 patients provided the hospital mortality. The pooled rates of hospital mortality in hyperuricemia group and control group were 8.9% (95% CI, 2.1-30.8%) and 5.0% (95% CI, 1.0-21.9%) respectively (OR 1.68, 95% CI 0.91-3.1, p = 0.083) (Figs. 2c and 8). The relationship between hyperuricemia and hospital mortality was not significant.
Fig. 8

Effects of hyperuricemia on hospital mortality

SUA levels in AKI and Non-AKI groups

Five studies assessed the SUA levels in AKI and Non-AKI groups. The pooled pre-operative SUA levels were higher in AKI group (376.35 μmol/L, 95% CI 321.76-430.93 μmol/L) than in Non-AKI group (317.09 μmol/L, 95% CI 304.50-329.68 μmol/L) (Std diff in means 0.860, 95% CI 0.334-0.112, p = 0.010) (Fig. 2d).

Publication bias

The funnel plots showed no evidence of publication bias. Egger’s test for a regression intercept gave a p-value of 0.696 for effects of hyperuricemia on incidence of AKI, indicating no publication bias.

Discussion

AKI is one of the most serious complications with a reported mortality rate of 15% in hospitalized patients [15]. Our meta-analysis showed that HUA is a critical and potential risk factor for the incidence of AKI, not only in preoperative patients as reported previously but also in all hospitalized patients.

In this meta-analysis, we found that the pooled rates of AKI incidence in hyperuricemia group were much higher than that in the control group. The underlying reasons were analyzed as follows. Firstly,majority of uric acid is excreted by the kidneys and accounts for 70%. It should be noted that approximately 90–95% of the filtered uric acid from glomerular is absorbed, mostly by proximal tubules [16, 17]. Secreted uric acid by the renal tubules is very little. Consequently the SUA concentration depends on glomerular filtration and subsequent tubular reabsorption function. There is mounting evidence to consider SUA as a clear marker for chronic kidney disease or an independent risk factor for the development of chronic kidney disease [18, 19]. A number of studies demonstrated that pre-existing chronic kidney disease increases the risk of AKI. Ishani et al. reported that the incidence of AKI was 8.8% in patients with chronic kidney disease versus 2.3% in patients without chronic kidney disease [20]. Pannu N et al. found that the risk of AKI was 18-fold higher in patients with an eGFR less than 30 ml/min/1.73 m2 than in those with an eGFR more than 60 ml/min/1.73 m2 [21]. Therefore, patients with increased SUA may already have the subclinical chronic renal dysfunction, leading them to be more vulnerable to AKI. In addition, we did an adjustment for the important covariate baseline GFR or serum creatinine. Unfortunately, there were only two included studies with equal renal function at admission, the results from which was more convincing.

Seconding, an elevated SUA concentration has been found to be associated with damage of impartment organs and result to many diseases such as hypertension [17, 22], metabolic syndrome [23], atherosclerosis [24], myocardial infarction [25], diabetes mellitus [4], stroke [26] and so on. All of the above diseases are most common risk factor of AKI, which make it sense that the incidence of AKI in the hyperuricemic patients is higher than those in the normouricemic patients.

A number of studies supported that uric acid is an independent risk factor of cardiovascular disease. The incidence rate of cardiovascular disease in patients with hyperuricemia is higher than that in the normal population [27]. A meta-analysis showed that incidence of coronary heart disease (CHD) in the hyperuricemic patients was 1.34 times (95% CI 1.19-1.49) than that in the normouricemic patients [5]. Patients with CHD combined with hyperuricemia have higher incidence of myocardial infarction. The global number of cardiac surgeries or PCI each year is approximately 2 million [28, 29] and one of the most common and serious post-operative complications is AKI. A current meta analysis found that the incidence of AKI after cardiac surgery was 22.3% around the world (95% CI 19.8-25.1) [2]. The incidence of PCI-induced AKI has been estimated between 2% and 30% depending mainly on baseline renal function, which is increasing along with the higher prevalence of CHD year by year [15, 29]. Our results suggest that higher pre-PCI SUA increased risk of AKI. We speculated that the patients with increased SUA maybe undergo more PCI, consequently have more incidence of AKI. In addition, it was found contrast agents have a uricosuric effect through enhancing renal tubular secretion of uric acid [30], which may promote renal injury caused by possible nephrotoxic effect of uric acid. However, there are more complex risk factors and mechanisms of AKI incidence after cardiac surgery than PCI, which led to less difference of the pooled rate of AKI between hyperuricemia and control group. Moreover, there need more studies to confirm the prognostic role of SUA in AKI incidence after cardiac surgery.

Finally, it is well-known that AKI is resulted from multiple and interactive pathways. Uric acid itself can cause AKI due to several mechanisms ranging from direct tubular toxicity (crystal induced injury) [9] to indirect injury (secondary to vasoconstriction, oxidative stress, inflammatory and so on). In both animal and human models, uric acid is found to inhibit proliferation and migration of endothelial cell and cause dysfunction and apoptosis of endothelial cell [31, 32]. Animal experimental studies suggest that uric acid may cause renal vasoconstriction via inhibiting of renal nitric oxide synthase to reduce product of nitric oxide in endothelial cell [31] and via stimulating of the renin-angiotensin system [32]. Renal vasoconstriction is a common pathogenic factor in the progression of AKI [33]. Inflammatory and oxidative stress are two of important mechanisms of AKI [34]. Experimentally, it has been found that uric acid activates inflammatory transcription factor nuclear factor-κB signaling pathway [35]. Increasing SUA also stimulates the expression of pro-inflammatory systemic cytokine i.e. tumor necrosis factor α [36], and the local chemokines, i.e. monocyte chemotactic protein 1 in the kidney [37]. High SUA levels induced oxidative damage of proximal tubule cell by activating nicotinamide adenine dinucleotide phosphate (NADPH) oxidase [38]. Therefore, SUA may be involved in the progress of AKI and contribute to higher incidence of AKI in the patients with hyperuricemia. Regardless of whether elevated SUA is solely a predictive factor of AKI or an independent risk factor of AKI, careful attention is warranted.

Thus, we wonder if uric acid lowering therapy could decrease the risk for developing AKI. At present, no trials showed that lowering SUA may provide benefit in preventing AKI. Allopurinol was once used in the hyperuricemic patients before cardiovascular surgery to reduce oxidative stress and then improve cardiovascular outcomes [39]. However, it was found that allopurinol couldn’t prevent the incidence of AKI after cardiac surgery in these studies [40]. After that, researchers confirmed the protective role of allopurinol in the renal ischemia/reperfusion injury in rats [41, 42]. In addition, in the cisplatin-induced AKI models, the uric acid lowering drugs rasburicase [43] and febuxostat [44] could attenuate renal injury by their antioxidant, anti-inflammatory, and cytoprotective effects. A prospective, randomized pilot trial with 26 cardiac surgery patients with hyperuricemia showed that there was no significant difference of postoperative serum creatinine between subjects receiving rasburicase and the control group. However, urine NGAL tended to be lower in the rasburicase group, which suggested that lowing uric acid before surgery might protect against renal tubular injury [45]. In Sezai A et al. study, febuxostat had a renoprotective effect with a significant earlier decrease of UA after cardiac surgery in hyperuricemic patients compared with allopurinol [46]. Therefore, we postulated that early intervention to decrease SUA levels may lower the risk of developing AKI.

Strengths and limitations

To the best of our knowledge, this study is the first to systematically evaluate the indicated effect of SUA on the incidence of AKI especially after cardiac surgery and PCI. It included data more than 75,000 patients from 18 studies. We analyzed these studies in detail considering the effect of renal function at admission and study design.

However, the present study may have limitations. Firstly, if there were more randomized controlled trials with high quality and large samples in this meta-analysis, these results would be more convincing. Secondly, Kanda et al. indicated that SUA level has a U-shaped association with loss of kidney function and low SUA (male <5 mg/dl; female <3.6 mg/dl) is also a candidate predictor of chronic kidney disease [47]. We are only focused on the role of hyperuricemia in AKI without referring hypouricemia which will need more studies in the future.

Conclusion

This meta-analysis demonstrated that elevated SUA levels could be associated with an increased risk of developing AKI especially in the patients after cardiac surgery and PCI.

Abbreviations

AKI: 

Acute kidney injury

CHD: 

Coronary heart disease

GFR: 

Glomerular filtration rate

OR: 

Odds ratio

PCI: 

Percutaneous coronary intervention

SUA: 

Serum uric acid

Declarations

Acknowledgments

None.

Funding

This work was supported by the Shanghai Key Laboratory of Kidney Disease and Blood Purification, Science and Technology Commission of Shanghai Municipality (14DZ2260200). The funding was used for analysis and interpretation of data.

Availability of data and materials

Pubmed, Web of Science, Cochrane Library, OVID and EMBASE databases were used to identify all relevant published articles for review. These articles are open to the public.

Authors’ contribution

XXL planned the study, searched the literature, assessed studies, extracted data, analyzed data and prepared the article. HJC searched the literature, assessed studies, extracted data, analyzed data and assisted in article preparation. SNN and CRY assisted in the data analysis. ZT assisted with the statistical analysis and editing of the manuscript. DXQ assisted in article review. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Not applicable.

Ethics approval and consent to participate

Not applicable.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Department of Nephrology, Zhongshan Hospital, Fudan University
(2)
Shanghai Institute of Kidney Disease and Dialysis
(3)
Shanghai Key Laboratory of Kidney Disease and Blood Purification

References

  1. Fang Y, Ding X, Zhong Y, Zou J, Teng J, Tang Y, Lin J, Lin P. Acute kidney injury in a Chinese hospitalized population. Blood Purif. 2010;30(2):120–6.View ArticlePubMedGoogle Scholar
  2. Hu J, Chen R, Liu S, Yu X, Zou J, Ding X. Global Incidence and Outcomes of Adult Patients With Acute Kidney Injury After Cardiac Surgery: A Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth. 2016;30(1):82–9.View ArticlePubMedGoogle Scholar
  3. Johnson RJ, Segal MS, Srinivas T, Ejaz A, Mu W, Roncal C, Sanchez-Lozada LG, Gersch M, Rodriguez-Iturbe B, Kang DH, et al. Essential hypertension, progressive renal disease, and uric acid: a pathogenetic link? J Am Soc Nephrol. 2005;16(7):1909–19.View ArticlePubMedGoogle Scholar
  4. Lytvyn Y, Perkins BA, Cherney DZ. Uric acid as a biomarker and a therapeutic target in diabetes. Can J Diabetes. 2015;39(3):239–46.View ArticlePubMedGoogle Scholar
  5. Kim SY, Guevara JP, Kim KM, Choi HK, Heitjan DF, Albert DA. Hyperuricemia and coronary heart disease: a systematic review and meta-analysis. Arthritis Care Res. 2010;62(2):170–80.Google Scholar
  6. Otomo K, Horino T, Miki T, Kataoka H, Hatakeyama Y, Matsumoto T, Hamada-Ode K, Shimamura Y, Ogata K, Inoue K, et al. Serum uric acid level as a risk factor for acute kidney injury in hospitalized patients: a retrospective database analysis using the integrated medical information system at Kochi Medical School hospital. Clin Exp Nephrol. 2015.Google Scholar
  7. Lee EH, Choi JH, Joung KW, Kim JY, Baek SH, Ji SM, Chin JH, Choi IC. Relationship between Serum Uric Acid Concentration and Acute Kidney Injury after Coronary Artery Bypass Surgery. J Korean Med Sci. 2015;30(10):1509–16.View ArticlePubMedPubMed CentralGoogle Scholar
  8. Barbieri L, Verdoia M, Schaffer A, Cassetti E, Marino P, Suryapranata H, De Luca G, Novara Atherosclerosis Study G. Uric acid levels and the risk of Contrast Induced Nephropathy in patients undergoing coronary angiography or PCI. Nutr Metab Cardiovasc Dis. 2015;25(2):181–6.View ArticlePubMedGoogle Scholar
  9. Roncal CA, Mu W, Croker B, Reungjui S, Ouyang X, Tabah-Fisch I, Johnson RJ, Ejaz AA. Effect of elevated serum uric acid on cisplatin-induced acute renal failure. Am J Physiol Ren Physiol. 2007;292(1):F116–122.View ArticleGoogle Scholar
  10. Garabed Eknoyan, Nathan W.Levin.K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002;39(2 Suppl 1):S1-266.Google Scholar
  11. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol. 2009;62(10):1006–12.View ArticlePubMedGoogle Scholar
  12. Susantitaphong P, Cruz DN, Cerda J, Abulfaraj M, Alqahtani F, Koulouridis I, Jaber BL, Acute Kidney Injury Advisory Group of the American Society of N. World incidence of AKI: a meta-analysis. Clin J Am Soc Nephrol. 2013;8(9):1482–93.View ArticlePubMedPubMed CentralGoogle Scholar
  13. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177–88.View ArticlePubMedGoogle Scholar
  14. Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21(11):1539–58.View ArticlePubMedGoogle Scholar
  15. Fang Y, Teng J, Ding X. Acute kidney injury in China. Hemodial Int. 2015;19(1):2–10.View ArticlePubMedGoogle Scholar
  16. Richette P, Bardin T. Gout. Lancet. 2010;375(9711):318–28.View ArticlePubMedGoogle Scholar
  17. Susic D, Frohlich ED. Hyperuricemia: A Biomarker of Renal Hemodynamic Impairment. Cardiorenal Med. 2015;5(3):175–82.View ArticlePubMedPubMed CentralGoogle Scholar
  18. Li LYC, Zhao Y, Zeng X, Liu F, Fu P. Is hyperuricemia an independent risk factor for new-onset chronic kidney disease?: a systematic review and meta-analysis based on observational cohort studies. BMC Nephrol. 2014;27:15–122.Google Scholar
  19. Feig DI. Uric acid: a novel mediator and marker of risk in chronic kidney disease? Curr Opin Nephrol Hypertens. 2009;18(6):526–30.View ArticlePubMedPubMed CentralGoogle Scholar
  20. Ishani A, Xue JL, Himmelfarb J, Eggers PW, Kimmel PL, Molitoris BA, Collins AJ. Acute kidney injury increases risk of ESRD among elderly. J Am Soc Nephrol. 2009;20(1):223–8.View ArticlePubMedPubMed CentralGoogle Scholar
  21. Pannu N, James M, Hemmelgarn BR, Dong J, Tonelli M, Klarenbach S. Modification of outcomes after acute kidney injury by the presence of CKD. Am J Kidney Dis. 2011;58(2):206–13.View ArticlePubMedGoogle Scholar
  22. 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(3):355–60.View ArticlePubMedGoogle Scholar
  23. Billiet L, Doaty S, Katz JD, Velasquez MT. Review of hyperuricemia as new marker for metabolic syndrome. ISRN Rheumatol. 2014;2014:852954.View ArticlePubMedPubMed CentralGoogle Scholar
  24. Zhao G, Huang L, Song M, Song Y. Baseline serum uric acid level as a predictor of cardiovascular disease related mortality and all-cause mortality: a meta-analysis of prospective studies. Atherosclerosis. 2013;231(1):61–8.View ArticlePubMedGoogle Scholar
  25. Yan L, Liu Z, Zhang C. Uric acid as a predictor of in-hospital mortality in acute myocardial infarction: a meta-analysis. Cell Biochem Biophys. 2014;70(3):1597–601.View ArticlePubMedGoogle Scholar
  26. Kanbay M, Segal M, Afsar B, Kang DH, Rodriguez-Iturbe B, Johnson RJ. The role of uric acid in the pathogenesis of human cardiovascular disease. Heart. 2013;99(11):759–66.View ArticlePubMedGoogle Scholar
  27. Okura T, Higaki J, Kurata M, Irita J, Miyoshi K, Yamazaki T, Hayashi D, Kohro T, Nagai R, Japanese Coronary Artery Disease Study I. Elevated serum uric acid is an independent predictor for cardiovascular events in patients with severe coronary artery stenosis: subanalysis of the Japanese Coronary Artery Disease (JCAD) Study. Circ J. 2009;73(5):885–91.View ArticlePubMedGoogle Scholar
  28. Parikh CR, Coca SG, Thiessen-Philbrook H, Shlipak MG, Koyner JL, Wang Z, Edelstein CL, Devarajan P, Patel UD, Zappitelli M, et al. Postoperative biomarkers predict acute kidney injury and poor outcomes after adult cardiac surgery. J Am Soc Nephrol. 2011;22(9):1748–57.View ArticlePubMedPubMed CentralGoogle Scholar
  29. Tehrani S, Laing C, Yellon DM, Hausenloy DJ. Contrast-induced acute kidney injury following PCI. Eur J Clin Inv. 2013;43(5):483–90.View ArticleGoogle Scholar
  30. Postlethwaite AE, Kelley WN. Uricosuric effect of radiocontrast agents. A study in man of four commonly used preparations. Ann Intern Med. 1971;74(6):845–52.View ArticlePubMedGoogle Scholar
  31. 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(5):1739–42.View ArticlePubMedGoogle Scholar
  32. Yu MA, Sanchez-Lozada LG, Johnson RJ, Kang DH. Oxidative stress with an activation of the renin-angiotensin system in human vascular endothelial cells as a novel mechanism of uric acid-induced endothelial dysfunction. J Hypertens. 2010;28(6):1234–42.PubMedGoogle Scholar
  33. Haase M, Bellomo R, Devarajan P, Schlattmann P, Haase-Fielitz A. Accuracy of neutrophil gelatinase-associated lipocalin (NGAL) in diagnosis and prognosis in acute kidney injury: a systematic review and meta-analysis. Am J Kidney Dis. 2009;54(6):1012–24.View ArticlePubMedGoogle Scholar
  34. Bonventre JV, Yang L. Cellular pathophysiology of ischemic acute kidney injury. J Clin Investig. 2011;121(11):4210–21.View ArticlePubMedPubMed CentralGoogle Scholar
  35. Zhou Y, Fang L, Jiang L, Wen P, Cao H, He W, Dai C, Yang J. Uric acid induces renal inflammation via activating tubular NF-kappaB signaling pathway. PLoS One. 2012;7(6), e39738.View ArticlePubMedPubMed CentralGoogle Scholar
  36. Netea MG, Kullberg BJ, Blok WL, Netea RT, van der Meer JW. The role of hyperuricemia in the increased cytokine production after lipopolysaccharide challenge in neutropenic mice. Blood. 1997;89(2):577–82.PubMedGoogle Scholar
  37. Kang DH. A Role for Uric Acid in the Progression of Renal Disease. J Am Soc Nephrol. 2002;13(12):2888–97.View ArticlePubMedGoogle Scholar
  38. Verzola D, Ratto E, Villaggio B, Parodi EL, Pontremoli R, Garibotto G, Viazzi F. Uric acid promotes apoptosis in human proximal tubule cells by oxidative stress and the activation of NADPH oxidase NOX 4. PLoS One. 2014;9(12), e115210.View ArticlePubMedPubMed CentralGoogle Scholar
  39. Simko LC, Walker JH. Preoperative antioxidant and allopurinol therapy for reducing reperfusion-induced injury in patients undergoing cardiothoracic surgery. Crit Care Nurse. 1996;16(6):69–73.PubMedGoogle Scholar
  40. Ejaz AA, Mu W, Kang DH, Roncal C, Sautin YY, Henderson G, Tabah-Fisch I, Keller B, Beaver TM, Nakagawa T, et al. Could uric acid have a role in acute renal failure? Clin J Am Soc Nephrol. 2007;2(1):16–21.View ArticlePubMedGoogle Scholar
  41. Willgoss DA, Zhang B, Gobe GC, Kadkhodaee M, Endre ZH. Repetitive brief ischemia: intermittent reperfusion during ischemia ameliorates the extent of injury in the perfused kidney. Ren Fail. 2003;25(3):379–95.View ArticlePubMedGoogle Scholar
  42. Rhoden E, Teloken C, Lucas M, Rhoden C, Mauri M, Zettler C, Bello-Klein A, Barros E. Protective effect of allopurinol in the renal ischemia--reperfusion in uninephrectomized rats. Gen Pharmacol. 2000;35(4):189–93.View ArticlePubMedGoogle Scholar
  43. Ejaz AA, Dass B, Kambhampati G, Ejaz NI, Maroz N, Dhatt GS, Arif AA, Faldu C, Lanaspa MA, Shah G, et al. Lowering serum uric acid to prevent acute kidney injury. Med Hypotheses. 2012;78(6):796–9.View ArticlePubMedGoogle Scholar
  44. Fahmi AN, Shehatou GS, Shebl AM, Salem HA. Febuxostat exerts dose-dependent renoprotection in rats with cisplatin-induced acute renal injury. Naunyn Schmiedeberg's Arch Pharmacol. 2016;389(8):819–30.View ArticleGoogle Scholar
  45. Bose B, Badve SV, Hiremath SS, Boudville N, Brown FG, Cass A, de Zoysa JR, Fassett RG, Faull R, Harris DC, et al. Effects of uric acid-lowering therapy on renal outcomes: a systematic review and meta-analysis. Nephrol Dial Transplant. 2014;29(2):406–13.View ArticlePubMedGoogle Scholar
  46. Sezai A, Soma M, Nakata K, Hata M, Yoshitake I, Wakui S, Hata H, Shiono M. Comparison of febuxostat and allopurinol for hyperuricemia in cardiac surgery patients (NU-FLASH Trial). Circ J. 2013;77(8):2043–9.View ArticlePubMedGoogle Scholar
  47. Kanda E, Muneyuki T, Kanno Y, Suwa K, Nakajima K. Uric acid level has a U-shaped association with loss of kidney function in healthy people: a prospective cohort study. PloS One. 2015;10(2), e0118031.View ArticlePubMedPubMed CentralGoogle Scholar
  48. Shacham Y, Gal-Oz A, Flint N, Keren G, Arbel Y. Serum Uric Acid Levels and Renal Impairment among ST-Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Intervention. Cardiorenal Med. 2016;6(3):191–197.View ArticlePubMedPubMed CentralGoogle Scholar
  49. Cheungpasitporn W, Thongprayoon C, Harrison AM, Erickson SB. Admission hyperuricemia increases the risk of acute kidney injury in hospitalized patients. Clin Kidney J. 2016;9(1):51–56.View ArticlePubMedGoogle Scholar
  50. Liang J, Zhang P, Hu X, Zhi L. Elevated serum uric acid after injury correlates with the early acute kidney in severe burns. Burns. 2015;41(8):1724–31.View ArticlePubMedGoogle Scholar
  51. Lazzeri C, Valente S, Chiostri M, Gensini GF. Long-term prognostic role of uric acid in patients with ST-elevation myocardial infarction and renal dysfunction. J Cardiovasc Med (Hagerstown). 2015;16(11):790–94.View ArticleGoogle Scholar
  52. Gaipov A, Solak Y, Turkmen K, Toker A, Baysal AN, Cicekler H, Biyik Z, Erdur FM, Kilicaslan A, Anil M et al. Serum uric acid may predict development of progressive acute kidney injury after open heart surgery. Ren Fail. 2015;37(1):96–102.View ArticlePubMedGoogle Scholar
  53. Guo W, Liu Y, Chen JY, Chen SQ, Li HL, Duan CY, Liu YH, Tan N. Hyperuricemia Is an Independent Predictor of Contrast-Induced Acute Kidney Injury and Mortality in Patients Undergoing Percutaneous Coronary Intervention. Angiology. 2015;66(8):721–26.View ArticlePubMedGoogle Scholar
  54. Joung KW, Jo JY, Kim WJ, Choi DK, Chin JH, Lee EH, Choi IC. Association of preoperative uric acid and acute kidney injury following cardiovascular surgery. J Cardiothorac Vasc Anesth. 2014;28(6):1440–47.View ArticlePubMedGoogle Scholar
  55. Xu J, Chen Y, Liang X, Hu P, Cai L, An S, Li Z, Shi W. Impact of pre-operative uric acid on acute kidney injury after cardiac surgery in elderly patients]. Zhonghua xin xue guan bing za zhi. 2014;42(11):922–26.PubMedGoogle Scholar
  56. Liu Y, Tan N, Chen J, Zhou Y, Chen L, Chen S, Chen Z, Li L. The relationship between hyperuricemia and the risk of contrast-induced acute kidney injury after percutaneous coronary intervention in patients with relatively normal serum creatinine. Clin. 2013;68(1):19–25.View ArticleGoogle Scholar
  57. Lapsia V, Johnson RJ, Dass B, Shimada M, Kambhampati G, Ejaz NI, Arif AA, Ejaz AA. Elevated uric acid increases the risk for acute kidney injury. Am J Med. 2012;125(3):302 e309-17.Google Scholar
  58. Ejaz AA, Kambhampati G, Ejaz NI, Dass B, Lapsia V, Arif AA, Asmar A, Shimada M, Alsabbagh MM, Aiyer R et al. Post-operative serum uric acid and acute kidney injury. J Nephrol. 2012;25(4):497–505.View ArticlePubMedGoogle Scholar
  59. Park S-H, Shin W-Y, Lee E-Y, Gil H-W, Lee S-W, Lee S-J, Jin D-K, Hong S-Y. The Impact of Hyperuricemia on In-Hospital Mortality and Incidence of Acute Kidney Injury in Patients Undergoing Percutaneous Coronary Intervention. Circ J. 2011;75(3):692–97.View ArticlePubMedGoogle Scholar
  60. Kim JH, Gil HW, Yang JO, Lee EY, Hong SY. Serum uric acid level as a marker for mortality and acute kidney injury in patients with acute paraquat intoxication. Nephrol Dial Transplant. 2011;26(6):1846–52.View ArticlePubMedGoogle Scholar
  61. Ben-Dov IZ, Kark JD.Serum uric acid is a GFR-independent long-term predictor of acute and chronic renal insufficiency: the Jerusalem Lipid Research Clinic cohort study. Nephrol Dial Transplant. 2011;26(8):2558–66.View ArticlePubMedPubMed CentralGoogle Scholar
  62. Toprak O, Cirit M, Esi E, Postaci N, Yesil M, Bayata S. Hyperuricemia as a risk factor for contrast-induced nephropathy in patients with chronic kidney disease. Catheter Cardiovasc Interv. 2006;67(2):227–35.View ArticlePubMedGoogle Scholar

Copyright

© The Author(s). 2017

Advertisement