Background

Hyperuricemia is a disease where the uric acid level is above 6.8 mg/dL. When purine breaks down very fast, then cells turn into muscle damage, blood cells breaking or tumors. In this condition, uric acid is produced in too many amounts, or it cannot leave the body as the kidney is not working properly or the body is acidic. Hyperuricemia may lead to kidney stones or gout. It is also associated with diabetes, heart problems, metabolic disease, and kidney disease.  

Epidemiology

Hyperuricemia does not appear to have any symptoms. Maybe about a quarter of patients have this condition. About 21 people out of 100 may have elevated uric acid levels without any symptoms. Hyperuricemia may lead to gout frequently. It affects about 4 in 100 Americans. The most common complication of hyperuricemia is gout. 

Anatomy

Pathophysiology

When the purine breaks down, uric acid is produced. It goes into the blood as the urate is at the normal pH of 7.4. The liver helps to break down uric acid. Other tissues with xanthine oxidase can also help. The kidney eliminates uric acid through urine and stool. The kidney filters it and reabsorbs it. Humans have more uricase than animals. Uricase is an enzyme. Uric acid accumulates when people consume too much from food or do not eliminate it from the body. Animal proteins and beer may increase the level of uric acid. Conditions like muscle breakdown or red blood cell damage can lead to the accumulation of uric acid. 

Etiology

Urate can ge­t made too much from some things. Like having lots of purine­s in your foods. Or errors in how your body works, like PRPP synthetase­ being overactive or HPRT be­ing missing. Exercise, polycythemia ve­ra, and diseases that make ce­lls grow too fast can also cause it. Sometimes your kidne­ys don’t get rid of uric acid right, from kidney problems or be­ing too acidic. Some medicines, like­ niacin and pyrazinamide, and toxins can do this too, plus not having enough fluid. Certain conditions, like­ sarcoidosis, not enough thyroid hormone, or too much parathyroid hormone, may be­ reasons too. Down syndrome, Bartter syndrome­, medications, and toxins could play a part as well. 

Genetics

Prognostic Factors

Clinical History

Elevated uric acid level is known as hyperuricemia. It has no symptoms. Healthcare providers find out this condition by regular blood tests. However, some symptoms include swelling, joint pain, redness and edema. Gout is a condition which is a complication of this condition. Gout can affect the big toe. High uric acid levels can lead to urate crystals in the joint (chronic gouty arthritis), kidney stones, or urate nephropathy. Other complications include nephrolithiasis (kidney stones causing renal colic and hematuria) and tophi (urate crystals under the skin, near joints). Hyperuricemia is linked to cardiac problems like high blood pressure, blockage of arteries, or strokes. It is also associated with obesity, metabolic diseases, or insulin resistance.  

Physical Examination

Hyperuricemia occurs without any symptoms. If it appears, it may be different. Acute gout targets the one joint which swell, appears red and hot, and painful. Tophi may lead to small, painful lumps in areas like ears, inner elbows, or forearms which have chronic gout. People who have uric acid kidney stones may feel side pain. In most cases of hyperuricemia, there are no clear symptoms of physical finding. Acute gouty arthritis affects a single joint, which becomes swollen, red, hot, and painful. Patients with high uric acid nephrolithiasis kidney stones may experience abdominal pain. 

Age group

Associated comorbidity

Hyperuricemia affects people at any age. It is associated with gout, swelling, redness, and sudden joint pain. When the urate crystals accumulate in the joints, this can lead to inflammatory arthritis. Increased levels of uric acid in blood may form crystals in kidneys. These can lead to kidney stones that need procedures to remove.  

Associated activity

Acuity of presentation

Regular blood tests for any other reason may find a high level of uric acid. The worst impact of high levels of uric acid is acute and painful arthritis. It can lead to intense pain. Redness, swelling, and edema. The big toe is affected. Sometimes, the ankles, knees, or wrists can also be affected. 

Differential Diagnoses

• Gout  
• Chronic Kidney Disease (CKD)  
• Diuretic Use 
• Lesch-Nyhan Syndrome  
• Psoriasis  
• Metabolic Syndrome  
• Alcohol Consumption  
• Lead Poisoning  
• Hypothyroidism 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

For elevated levels of uric acid, most people who have no kidney stones or gout do not need medical attention. Patients who are having cancer treatment, which kills the cells, may need uric acid-lowering medications. This can avoid tumor lysis syndrome. Medications which can lower the level of uric acid include is probenecid. It helps to remove kidney stones. It is a second treatment option for gout. Allopurinol prevents the production of uric acid and prevents gout and kidney stones. Rasburicase converts uric acid to water-soluble components.  

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

use-of-non-pharmacological-approach-for-hyperuricemia

Some foods which contain uric acid should be avoided. Organ meats and shellfish are high in purine. Alcohol like spirits or beers can increase the levels of uric acid. Patients should drink plenty of water. Water helps to dilute and remove uric acid via urine. One should maintain a healthy weight as obesity can lead to increased risk of gout. Weight loss lowers the risk of hyperuricemia and gout. Regular exercise can reduce the uric acid in the blood.  

Use of Xanthine Oxidase Inhibitors

Allopurinol: Allopurinol can block an enzyme xanthine oxidase. It reduces the uric acid level in blood. It is the first treatment option for gout. It also prevents gout attack. 

Febuxostat: Febuxostat works like allopurinol. It also decreases the production of uric acid by blocking the actions of xanthine oxidase. Healthcare provider prescribes this medication when patient can not take allopurinol. 

Use of Selective Uric acid Reabsorption Inhibitor (SURI)

Lesinurad: Lesinurad blocks the uric acid which is reabsorbed by the kidney. It is used along with the other medication which can prevent the production of uric acid. Healthcare providers prescribe this to treat patients who have gout and increase the levels of uric acid in the blood.  

Use of Uricosuric Agents

Probenecid: Probenecid prevents the reabsorption of uric acid in the kidneys. This can lead to more elimination of uric acid via urine. Doctors suggested this medication to patients who have low uric acid elimination and norma kidney function. Probenecid works as a uricosuric agent. It elevates the urinary excretion of uric acid via urine.  

Use of Antigout Agents

Colchicine: Colchicine helps to reduce inflammation. It is useful to treat gout attacks. It blocks the inflammatory pathways. It prevents the white blood cells to move towards the painful joint areas. 

Use of Glucocorticoids

Prednisone: Prednisone is a synthetic steroid. It reduces the swelling. It blocks the chemicals which can trigger inflammation. It prevents the immune cells from responding. 

Dexamethasone: Dexamethasone is the same as prednisone. It lasts longer and has a strong effect. It is also a synthetic steroid. 

Use of Urate Oxidase Enzyme

Pegloticase: Uric acid is hard to dissolve. Pegloticase is an enzyme. It converts the uric acid into allantoin. Allantoin is soluble and easy for elimination by kidney. Pegloticase is a synthetic drug.  

use-of-intervention-with-a-procedure-in-treating-hyperuricemia

Plasmapheresis is a therapeutic apheresis. Certain blood components are removed like plasma or proteins. Then, the blood returns to the body. This procedure may benefit some of the cases. High levels of uric acid-containing plasma are eliminated during plasma exchange. It is switched to fresh plasma fluid from the donor. The blood components are filtered and then returned to the body of the patient.  

use-of-phases-in-managing-hyperuricemia

Drugs like NSAIDs, colchicine, or steroids can be used in some cases of gout to reduce the pain and swelling. It is necessary to change the diet, drink more water, and lose some extra weight. Exercise will also help treat hyperuricemia.  

Medication

Future Trends

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References

https://www.ncbi.nlm.nih.gov/books/NBK459218/ 

https://emedicine.medscape.com/article/241767-clinical#b2 

Hyperuricemia – StatPearls – NCBI Bookshelf (nih.gov)