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Hyperuricemia prevalence and its risk factors in uremic patients undergoing maintenance hemodialysis

BMC Nephrology volume 26, Article number: 46 (2025) Cite this article

Abstract

Background

To explore the prevalence of hyperuricemia and its associated factors in uremic patients undergoing maintenance hemodialysis (MHD).

Methods

Two hundred two uremic patients undergoing MHD for ≥ 3 months, in Jinshan Hospital, Fudan University, were enrolled. Pre-dialysis blood samples were tested during March 1st, 2023 to April 30th, 2023. Demographic characteristics were recorded. The prevalence of hyperuricemia, defined as serum uric acid (SUA) ≥ 420 μmol/L, was investigated. Individuals were divided into hyperuricemia (HUA) and non-hyperuricemia (n-HUA) groups. The demographic characteristics, residual kidney function, nutritional status, acid–base metabolism, electrolyte and lipid metabolism were compared between groups. The associated factors for hyperuricemia in MHD patients were identified by logistic regression.

Results

The median SUA level of the enrolled patients was 458.50 (392.25, 510.75) μmol/L. 134 (66.34%) candidates met the diagnostic criteria of hyperuricemia. The median SUA level in HUA group was 491.00 (459.50, 543.50) μmol/L. Compared to those in n-HUA group, subjects in HUA group showed lower estimated glomerular filtration rate and blood CO2 level, but higher levels of body mass index, geriatric nutritional risk index, plasma phosphate, potassium, pre-albumin, albumin, serum creatinine (Scr) and urea nitrogen. Logistic regression indicated that Scr (OR 1.002, 95% CI 1.001–1.004, P = 0.003), albumin (OR 1.165, 95%CI 1.011–1.342, P = 0.035), and blood potassium (OR 1.673, 95% CI 1.009–2.773, P = 0.046) were associated factors for hyperuricemia in uremic patients undergoing MHD.

Conclusion

Hyperuricemia was highly prevalent among uremic MHD patients. Elevated levels of Scr, albumin and plasma potassium were independent associated factors for hyperuricemia.

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Introduction

Uric acid was the final product of purine metabolism, of which 2/3 was excreted through kidneys [1]. Therefore, as renal function progressively deteriorated, serum uric acid (SUA) levels increased [2], resulting in the high prevalence of hyperuricemia (HUA), which was defined as SUA level exceeding 420 μmol/L [3]. The prevalence of hyperuricemia among common Chinese adults reached 14.6% in 2015 according to the China nutrition and health surveillance [4]. In comparison, the prevalence of hyperuricemia was 27.5% in hemodialysis patients from European Clinical Database [5]. Maintenance hemodialysis (MHD) can clear uric acid away from the blood [6]. However, it was insufficient to avoid hyperuricemia due to the intermittent nature of hemodialysis, the varied pore sizes of dialyzers and the personalized diet habits [7].

Previous study showed that the risk of all-cause mortality exhibited a U-shaped relationship with serum uric acid levels in hemodialysis patients [8].Therefore, high uric acid levels were a risk factor for all-cause mortality and cardiovascular death in patients receiving hemodialysis [9], which may partly explain why the prescription of allopurinol was associated with lower all-cause mortality in hemodialysis patients without prior history of cardiovascular disease [10]. Besides, given that hyperuricemia was a significant risk factor for gout [3], it was reasonable to observe that the prevalence of gout was 13% in hemodialysis patients [11]. In this population, gout increased the risk of death and cardiovascular disease-related hospitalization [12]. Considering the reduced risk of gout and potential survival benefit caused by uric acid-lowering therapy [13], it was valuable to manage the excessive SUA levels in hemodialysis population. From a different perspective, evidences suggested that high concentrations of SUA was associated with better nutritional status in MHD patients [14]. Therefore, it was crucial to maintain SUA levels within an appropriate range in uremic patients receiving MHD. However, there was currently no consensus on whether hyperuricemia required strict control in uremic patients undergoing MHD. More clinical data on hyperuricemia will help to make a comprehensive decision in future. Hereby, a single-center cross-sectional survey on the prevalence of hyperuricemia and its associated factors in uremic MHD population, Shanghai, China, was reported.

Materials and methods

Participants

Inclusion criteria were patients who underwent MHD over 3 months due to chronic kidney disease (CKD) G5, eGFR < 15 mL/min/1.73m2 regardless of the albuminuria. Exclusion criteria were patients under hemodialysis because of acute renal failure, congestive heart failure or pulmonary edema, and those with newly diagnosed solid tumors, hematological malignancies, lymphomas within the last 3 months, nasogastric tube feeding within the last 2 weeks and the pregnant ones. A total of 287 CKD G5 patients underwent hemodialysis at Jinshan Hospital affiliated to Fudan University, and 85 patients were excluded. Finally, there were 202 subjects enrolled in this study from March 1, 2023 to April 30, 2023. Each patient underwent dialysis three times per week, with each session lasting four hours. The blood flow rate ranged from 200 to 250 ml/min.

Hemodialysis was performed using Fresenius Medical Care 4008/5008 hemodialysis machines. Low molecular weight heparin was injected for circular anticoagulation.

Methods

Demographic information

Primary etiologies, dialysis duration, Kt/V, gender, age, and other personal data were collected from the "Xuetoutong" electronic information system (Xuetoutong Medical Technology Corporation, China, version 1.3.11.18).

Measurements of pre-dialysis blood biochemistry indexes

3 mL fasting venous blood was harvested before the mid-week hemodialysis (on Tuesday or Wednesday). Then the serum was measured for blood urea nitrogen (BUN), creatinine (Scr), uric acid (UA), homocysteine (Hcy), triglyceride (TG), total cholesterol (TCH), low density lipoprotein (LDL), high density lipoprotein (HDL), prealbumin (PAB), albumin (Alb), alanine aminotransferase (ALT), aspartate aminotransferase (AST), calcium (Ca), phosphorus (P) using an automatic biochemical analyzer (BS-2800M, mindray corporation, China). 25-hydroxyvitamin D3 (25OHD3) and intact parathyroid hormone (iPTH) were measured by an automated chemiluminescence immunoassay analyzer (MAGLUMI X8, snibe corporation, China). Hemoglobin (Hb) was measured by the blood cell analyzer (XN9000, sysmex corporation, Japan).

Adjusted calcium concentration and calcium—phosphorus product

For patients with hypoproteinemia, calcium concentration was adjusted by albumin: adjusted calcium concentration (mmol/L) = actual calcium concentration (mmol/L) + [40-albumin (g/L)] × 0.02 [15]. Then calcium and phosphorus product (mmol/L)2 was calculated as adjusted calcium concentration (mmol/L) × phosphate (mmol/L).

Residual renal function

Estimated glomerular filtration rate (eGFR) was calculated by Cockcroft-Gault equation [16], representing the residual renal function for uremic MHD patients.

Body Mass Index (BMI) & Geriatric Nutritional Risk Index (GNRI).

The BMI was calculated by dividing an individual's body weight in kilograms by the square of the height in metres. The GNRI was used to assess the nutritional status, based on serum albumin levels, height, and weight [17], which was calculated as follow:

$$\text{GNRI }= [ 1.489 \times \text{ albumin }(\text{g}/\text{L}) ] + [ 41.7 \times (\text{ body weight }/\text{ ideal body weight }) ].$$

Statistics

Python (version 3.8.10, www.python.org) was used for statistical analysis. Continuous variables were expressed as \(\overline{\text{x}}\pm \text{s }\) or M (P25, P75), followed by one-way ANOVA or Kruskal–Wallis test. Categorical variables were expressed as percentages (%), followed by χ2 test or Fisher's exact test. Logistic regression analysis was used to explore the associated factors for hyperuricemia in uremic patients undergoing MHD. P < 0.05 was considered statistically significant.

Results

Baseline characteristics

A total of 202 uremic patients undergoing MHD were included, with 124 males (61.39%) and 78 females (38.61%). The median age was 61.00 (50.00, 71.00) years old, and the median hemodialysis duration was 58.47 (20.78, 123.98) months. The primary etiologies of end-stage renal disorders were chronic glomerulonephritis (51.49%), diabetic nephropathy (18.32%), hypertensive nephropathy (9.90%), ischemic kidney disease (7.92%), polycystic kidney disease (4.95%), tubulointerstitial nephropathy (2.97%), lupus nephritis (1.98%), obstructive kidney disease (0.99%), amyloidosis (0.50%), ANCA associated glomerulonephritis (0.50%), and multiple myeloma (0.50%) (Table 1).

Table 1 Baseline characteristics in MHD patients with and without HUA
Full size table

SUA levels and the prevalence of hyperuricemia

The median SUA level of 202 uremic MHD patients was 458.50 (392.25, 510.75) μmol/L. 134 out of the enrolled subjects (66.34%) met the diagnostic criteria of hyperuricemia (SUA ≥420 μmol/L).

Biochemical markers in uremic patients undergoing MHD stratified by SUA levels

Patients were divided into HUA group and non-HUA (n-HUA) group according to the SUA levels. Individuals in HUA group exhibited higher SUA concentration than those without (491 μmol/L vs. 370 μmol/L, P < 0.001). Demographic information, residual renal function, nutritional status, electrolytes, lipid metabolism, and homocysteine levels were compared between groups. The age, gender ratio and hemodialysis duration were comparable. Subjects with hyperuricemia had less eGFR and lower blood CO2, but higher levels of BMI, GNRI, serum phosphate, potassium, prealbumin, albumin, serum creatinine, and blood urea nitrogen in contrast to those without hyperuricemia. No significant difference was noticed as to other indexes listed (Table 1).

HUA prevalence in uremic patients undergoing MHD stratified by gender

All candidates were further stratified according to the gender. The females shared the similar age as the males. Meanwhile, both SUA levels and the prevalence of hyperuricemia showed no significant differences between subgroups (Table 2).

Table 2 The prevalence of hyperuricemia in female and male subgroups
Full size table

HUA prevalence in MHD patients with varied hemodialysis duration

Patients were subdivided based on the hemodialysis duration, that is, the 25th percentile (20.78 months), median (58.47 months), and 75th percentile (123.98 months). SUA levels and HUA prevalence were then analyzed. As a result, neither SUA concentration nor HUA prevalence showed obvious difference among four subgroups (Table 3).

Table 3 HUA prevalence in patients stratified by hemodialysis duration
Full size table

HUA prevalence in patients with and without diabetes

To investigate whether the disorder of glucose metabolism affected the prevalence of hyperuricemia in uremic patients undergoing MHD, subjects were stratified into non-diabetic (n-DM) and diabetic (DM) groups. The SUA levels and prevalence of hyperuricemia were compared between subgroups. The results indicated no remarkable differences as to both SUA levels and hyperuricemia prevalence (Table 4).

Table 4 The prevalence of hyperuricemia with and without diabetes mellitus
Full size table

Associated factors for hyperuricemia in uremic patients undergoing MHD

Univariate logistic regression was first performed to explore the potential independent variables for hyperuricemia. The chosen variables were then included in a following multivariate logistic regression to investigate the associated factors for hyperuricemia in uremic patients undergoing MHD (Table 5). The results showed that serum creatinine (OR: 1.002, 95%CI: 1.001–1.004, P = 0.003), albumin (OR: 1.165, 95%CI: 1.011–1.342, P = 0.035), and blood potassium (OR: 1.673, 95%CI: 1.009–2.773, P = 0.046) were associated factors for hyperuricemia in this enrolled uremic population (Table 5).

Table 5 Associated factors for hyperuricemia in uremic patients undergoing MHD
Full size table

Discussion

Uric acid was mostly excreted by kidneys. Therefore, the level of SUA was affected dramatically by renal function [2]. A retrospective survey investigated 16,057 hemodialysis patients in 564 NephroCare centers from 22 countries [5]. In this study, the median dialysis duration was 3.6 months, and the proportion of patients with SUA over 7 mg/dL was 27.5% [5]. In this single-center study from Shanghai, China, the prevalence of hyperuricemia among MHD uremic patients reached 66.34%, which was markedly higher than 27.5% in the previous report [5]. Notably, the median dialysis duration of patients in our study was 58.47 months, in contrast to 3.6 months as reported [5], suggesting that the progressive loss of residual renal function as hemodialysis vintage prolonged further weakened the excretion of uric acid from kidneys. In addition, increased SUA levels may indicate a satisfactory nutritional status in MHD patients as reported before [14, 18, 19]. KDIGO recommended an improved protein diet for regular dialysis patients compared to those waiting for blood purification [20]. The increased ingestion consequently enhanced the sources of exogenous purine, resulting in overproduction of uric acid [20]. Thus, high prevalence of hyperuricemia observed in this study may at least result from the above factors.

In a study, all recruited hemodialysis patients were stratified based on SUA levels (≤ 5, 5–6, 6–7.1, > 7.1 mg/dL). The result showed that the corresponding hemodialysis duration was 3.1, 3.5, 3.6, and 4.2 months, respectively [5]. This evidence implied that SUA levels mildly increased in newly hemodialysis individuals as hemodialysis duration prolonged, despite of the unclear mechanism. To investigate whether the prevalence of hyperuricemia was affected by hemodialysis duration, uremic MHD patients in our center were divided into subgroups according to dialysis duration. Unexpectedly, no significant correlation was observed between dialysis duration and SUA levels in enrolled individuals. As mentioned, these patients spent more accumulated time, 58.47 months, on MHD, and their eGFR declined to 3.88 ml/min/1.73m2. Considering the limitations of small sample size and single center data in this study, an expanded study will be needed. Besides, subgroup analysis of complications will also be conducted to further elucidate the impact of hemodialysis duration on SUA level after excluding confounding factors.

Gender was associated with the prevalence of hyperuricemia. In general population, the prevalence of hyperuricemia in premenopausal women was lower than that in men [4] and postmenopausal women [21, 22]. In uremic patients undergoing MHD, men were similarly prone to develop hyperuricemia compared to women [18, 23, 24]. However, the relationship between the prevalence of hyperuricemia and gender was not observed among MHD patients with similar age in this study. MHD patients with different gender exhibited a convergence in uric acid metabolism. This result may be partly explained by the fact that the enrolled females were in their elderly periods, with a median age of 62 years old. The majority of female patients in this study had already experienced menopause and was supposed to produce less estrogen, which weakened its inhibitory effect on hyperuricemia. Direct measurement of estrogen levels in our further work will be more persuasive.

Fractional excretion of uric acid was reduced by insulin in rats, which was mediated by increased expression of URAT1 and decreased levels of ABCG2 in kidneys, both of which were responsible for transportation of uric acid [25]. In addition, serum levels of UA were decreased among patients with type 1 diabetes compared with healthy individuals [26], implying that high levels of insulin were responsible for hyperuricemia. There were studies showing that hyperuricemia increased the risk of new-onset type 2 diabetes [27]. All the evidence above suggested that diabetes mellitus affected SUA levels. However, our study found that as the primary disease, diabetes did not affect SUA levels and the prevalence of hyperuricemia in uremic patients undergoing MHD. This phenomenon may be related to the use of medications that affected SUA levels in diabetic patients, such as losartan [28] and fenofibrate [29]. The patients’ medication records will be collected in subsequent studies to eliminate this confounding factor.

In this study, both serum albumin and serum creatinine were identified as associated factors for hyperuricemia in MHD patients with uremia. Serum albumin and creatinine were proved as nutritional markers [14]. Higher SUA level was associated with better nutritional status as well [14, 19], and lowered the all-cause mortality in this population [18]. Whereas, less SUA was related to higher risk of all-cause mortality and cardiovascular mortality in hemodialysis patients [30], which may result from poor nutritional condition. Proper levels of serum albumin and creatinine were supposed to be associated with a purine-rich diet, which resulted in the production of endogenous uric acid.

MHD patients with hyperuricemia had lower eGFR in comparison to those without, indicating that hyperuricemia was associated with poor residual renal function in population receiving MHD. Similarly, it was observed that SUA was negatively associated with eGFR in CKD patients [31].

Hyperkalemia was frequently reported in uremic patients [32], which caused serious consequences, such as cardiac arrhythmia [33]. Interestingly, serum potassium turned out to be an independent associated factor for hyperuricemia in enrolled MHD patients. Elevated SUA levels therefore might be associated with hyperkalemia in MHD uremic patients.

The association between homocysteine and SUA was not observed in our study. However, the median level of homocysteine in MHD patients was higher than the normal range. Considering that low levels of homocysteine reduced the risk of cardiovascular events in hemodialysis patients [34, 35], it was speculated that the treatment of hyperhomocysteinemia in MHD patients reduced the risk of cardiovascular diseases, which needed to be confirmed by other studies.

There were limitations in our study. First, a multicenter study with enlarged sample size will offer more persuasive evidence. Second, patients’ long-term prognosis should be included to evaluate the influence of hyperuricemia. Also, uremia may result from varied causes, while the present cases enrolled could not include all the possible etiologies. There was inevitable selection bias. These problems need a careful improvement in further study.

In summary, this single-center cross-sectional study found that hyperuricemia was highly prevalent in uremic patients undergoing MHD despite of intermittent clarification through hemodialysis [6]. High levels of serum creatinine, albumin and potassium were identified as independent associated factors for hyperuricemia in this population.

Data availability

The data used in the study are available from the corresponding author.

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Acknowledgements

Not applicable.

Funding

This work was supported by Shanghai Municipal Commission of Health and Family Planning (grant no. 201840271).

Author information

Authors and Affiliations

  1. Department of Nephrology, Jinshan Hospital Affiliated to Fudan University, Shanghai, China

    Meng Zhang, Gaoqiankun Huang, Xiaorong Bao & Qingmei Yang

  2. Nephrology Department, Shanghai Public Health Clinical Center, Fudan University, Shanghai, China

    Qingmei Yang

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Contributions

Data collection was performed by Gaoqiankun Huang. Data analysis and writing were done by Meng Zhang. Various useful suggestions were given by Xiaorong Bao. Qingmei Yang was responsible for study design. All authors have read and approved the final version of the manuscript.

Corresponding author

Correspondence to Qingmei Yang.

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Ethics approval and consent to participate

All experiments were performed in accordance with the Helsinki Declaration. The study was approved by the Ethics Committee of Jinshan Hospital Affiliated to Fudan University (JIEC 2023-S58). All included patients were fully informed about the study details and provided written informed consent prior to participation.

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Not applicable.

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Zhang, M., Huang, G., Bao, X. et al. Hyperuricemia prevalence and its risk factors in uremic patients undergoing maintenance hemodialysis. BMC Nephrol 26, 46 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12882-025-03978-8

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12882-025-03978-8

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BMC Nephrology

ISSN: 1471-2369

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