Kashif Ali Fazlani et al, (2017) Serum Uric Acid Level in Patients with Diabetes Mellitus Attending a Tertiary Care Hospital. Int J clinical & case. 1:2, 46-50.

International Journal of Case Studies in Clinical Research ISSN 2572-102X Research Article Open Access Serum Uric Acid Level in Patients with Diabetes Mellitus Attending a Tertiary Care Hospital Kashif Ali Fazlani1*, Bedarbakhat Khan2, Rehan Ahmed Jokhio3 1Department of Medicine, Government Hospital Qasimabad Hyderabad 2Medical Unit – IV, Ward-6, Liaquat University of Medical & Health Sciences, Jamshoro / Hyderabad 3Medical Registrar, King Fahad Armed Forces Hospital Jeddah *Corresponding Author: Kashif Ali Fazlani, Department of Medicine, Government Hospital Qasimabad Hyderabad, Email: [email protected] Citation: Kashif Ali Fazlani et al, (2017) Serum Uric Acid Level in Patients with Diabetes Mellitus Attending a Tertiary Care Hospital. Int J clinical & case. 1:2, 46-50. Copyright: © 2017 Kashif Ali Fazlani et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Received February 10, 2017; Accepted February 21, 2017; Published February 28, 2017.

Abstract Introduction: Serum uric acid (SUA) is positively associated with serum glucose levels in healthy subjects. Recent studies have demonstrated that UA levels are higher in subjects with prediabetes and early Type-II diabetes then in healthy controls. Furthermore, an elevated serum UA level was found to increase chances for developing Type-II diabetes in individuals with impaired glucose tolerance. Objectives: To determine the mean serum uric acid level in patients with diabetes mellitus attending a tertiary care hospital. Study Design: Cross-sectional Study. Setting: All medical wards of Liaqat University of medical and health sciences. Hyderabad, Jamshoroo. Duration: Six months from June 23, 2010 to December 22, 2010 Subjects and methods: A total of 138 cases fulfilling the inclusion criteria diagnosed as defined earlier were enrolled in the study by the Principle Investigator (PI). Brief history was taken regarding the duration of DM. A serum uric acid request was made from the institutional laboratory. Serum uric acid level was noted. This information as well as data regarding age, gender, duration of diabetes Mellitus, and Hypertension status was entered in the proforma. Results: The mean age was 57.5 ± 12.3 years with Male: Female = 1.2: 1. Overall mean serum uric acid was 13.3 ±2.5 mg/dL (Min – Max = 3 – 16 mg/dL). Out of 138 cases, 84 (60.9%) of cases had serum uric acid level > 7 mg/dL. The mean value of serum uric acid was 15.1 ±1.9 mg/dL in men and 11.2 ±3.1 mg/dL in women. Conclusion: In conclusion, this study showed significantly elevated serum uric acid 13.3 ±2.5 mg/dL in patients with Type-II diabetes.

Keywords: Mental Health, Life Satisfaction, Aged People. Introduction found to be 5.51±1.14 in men and 3.64±1.14 in women12. In a recent In recent years the burden of hyperuricemia has been on the study patients with diabetes Mellitus had serum uric acid level 13 rise in developed as well as in developing countries. It has 16.5±5.98 mg/dl . Metabolic syndrome and insulin resistance are been suggested that hyperuricemia is associated with metabolic well-established key risk factors for diabetes. Hyperuricemia, a syndrome1-2 Increased serum uric acid levels have been reported highly prevalent condition in the adult population, is associated 14 to be associated with hypertension3, diabetes4, obesity5, insulin with obesity and insulin resistance . Although much of the resistance6, dyslipidemia7, cardiovascular diseases8, peripheral literature addresses the association of hyperuricemia, hypertension, 15-16 arterial disease9, markers of inflammation10, and oxidative stress11. and renal disease , the role of uric acid in diabetes risk remains In subjects with FBG >110 mg/dl the mean serum uric acid was controversial. Recent evidence suggests that uric acid plays a role

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46 Kashif Ali Fazlani et al, (2017) Serum Uric Acid Level in Patients with Diabetes Mellitus Attending a Tertiary Care Hospital. Int J clinical & case. 1:2, 46-50.

in immune activation17 and cytokine secretion18. Moreover, uric (PI). Informed consent was taken from the patient for inclusion acid has been identified as a mediator of endothelial dysfunction in the study after explaining the pros and cons. Brief history was and systemic inflammation19. Previous cross-sectional data taken regarding the duration of DM-II. A serum uric acid request showed that hyperuricemia to be prevalent among individuals was made from the institutional laboratory. Serum uric acid level with metabolic syndrome20, but the data regarding prevalence of was noted. This information as well as data regarding age, gender, serum uric acid in diabetes Mellitus is limited. Therefore this study duration of diabetes Mellitus, and Hypertension status was entered is planned with an intent generate local data and to gain clarity. in the proforma. Secondly based on this data appropriate action may be taken to Data Analysis address this modifiable factor to decrease the morbidity. Data was entered and analyzed on SPSS version 16. Mean The objective of the present study was to determine the mean ±SD was calculated for age, serum uric acid level and duration serum uric acid level in patients with diabetes mellitus attending a of DM. Frequency and percentages was calculated for gender. tertiary care hospital. Stratification of age, gender, duration of DM, was done to control Material & Methods effect modifiers. Setting: All medical wards of Liaqat University of medical and Results health sciences. Hyderabad, Jamshoroo. Cross sectional Study A total of 138 patients with type-II diabetes of age between 40 the duration of the study was six months from June 23, 2010 to – 70 years were included in this study. The mean age was 57.5 December 22, 2010. Sampling technique was consecutive and ±12.3 years. Majority 77 (55.8%) of cases had age between 40 sample size of Patients of type 2 diabetes mellitus were required – 54 years. Figure-1 Among 138 patients, 74 (53.6%) were men to achieve the objective. Sample size calculated on the basis of the and 64 (46.4%) were women (Male: Female = 1.2: 1). Figure-2 following Duration of diabetes is presented in Figure-3. Mean duration of M=16.5mg/dl diabetes was 5.6 ±2.3 years. Majority 83 (60.1%) of diabetic cases presented with ≥ 5 years. Table-1 showed the mean value of serum SD= ±5.98 uric acid and the proportions. Overall mean serum uric acid was Confidence level=95% 13.3 ±2.5 mg/dL (Min – Max = 3 – 16 mg/dL). Out of 138 cases, 84 (60.9%) of cases had serum uric acid level > 7 mg/dL. Table-2 Bond on error=1mg/dl showed the mean value of serum uric acid in different age groups. n=138 patients The mean value of serum uric acid was 12.1 ±2.9 mg/dL in age between 40 – 54 years and 14.9 ±1.3 mg/dL in age between 55 – 69 Inclusion Criteria years. Table-3 showed the mean value of serum uric acid for both • Patient of Type 2 DM genders. The mean value of serum uric acid was 15.1 ±1.9 mg/ dL in men and 11.2 ±3.1 mg/dL in women. Mean value of serum • Duration of DM ≥ 6 months uric acid was also calculated with respect to duration of diabetes • Irrespective of gender (Table-4) • Age 40-70 year Exclusion Criteria Following patients were excluded from the study Figure-1 AGE DISTRIBUTION n = 138

• Acute ischemic stoke 100 77 (55.8%) • Immunocompromised patients like cirrhosis of liver, cardiovascular 75 61 (44.2%) diease 50 • Hypertension 25 Number of cases of Number • Type-I DM 0 • Obesity 40 - 54 55 - 69 Age (years) • Dyslipidemia Mean ±SD = 57.5 ±12.3 years • Peripheral arterial disease Data collection In-Patients meeting the inclusion criteria diagnosed as defined earlier were enrolled in the study by the Principle Investigator

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47 Kashif Ali Fazlani et al, (2017) Serum Uric Acid Level in Patients with Diabetes Mellitus Attending a Tertiary Care Hospital. Int J clinical & case. 1:2, 46-50.

Figure-2 GENDER DISTRIBUTION n = 138 Table-3 MEAN SERUM URIC ACID IN GENDER WITH TYPE-II DIABETES n = 138

Gender Mean ±SD Min - Max Male 15.1 ±1.9 5 - 16 Female 64 (46.4%) Female 11.2 ±3.1 3 - 12 Male 74 (53.6%) Table-4 MEAN SERUM URIC ACID WITH RESPECT TO DURATION OF DIABETES n = 138 Male: Female = 1.2: 1 Duration Mean ±SD Min - Max < 5 years 11.0 ±5.5 3 - 12 Figure-3 DURATION OF DIABETES n = 138 ≥ 5 years 15.1 ±2.1 3 - 16 Discussion Uric acid is end product of purine metabolism; it is filtered in < 5 years glamorous filtration and excreted in urine. Hyperuricemia is 55 (39.9%) most commonly defined by serum uric acid concentration greater than 7 mg/dl in man and 6 mg/dl in women.21 for patients in ≥ 5 years type-II diabetes, high serum uric acid may be the early sign of 83 (60.1%) diabetes nephropathy before any significance change in urine albumin level. 22 Hyperuricemia is an increasingly common medical problem not only in the advanced countries, but also in Mean ±SD = 5.6 ±2.3 years the developing countries. It has been described that hyperuricemia is associated with metabolic syndrome components1,2. Increased Table-1 SERUM URIC ACID LEVELS IN PATIENTS WITH serum uric acid levels have been reported to be associated TYPE-II DIABETES n = 13 with hypertension3, diabetes4, obesity5, insulin resistance6, dyslipidemia7, cardiovascular diseases8 peripheral arterial disease9, Serum Uric Number Percent Mean Min – markers of inflammation10, and oxidative stress11. In a study of 3 Acid of Cases ±SD Max 681 Japanese adult, it was found that an elevation of serum uric mg/dL mg/dL mg/dL acid concentration in males increased the risk of type-II diabetes24. It was concluded that hyperuricemia was positively associated Under 6 10 7.2% 13.3 3 - 16 with hyperglycemia. Insulin resistance may be the linking between ±2.5 6 – 7 44 31.9% them23. Serum uric acid is positively associated with serum glucose Over 7 84 60.9% in healthy subjects. However, this association is not consistent between healthy and diabetic individuals24,25, as a low serum level Table-2 MEAN SERUM URIC ACID IN AGE GROUPS WITH of uric acid is reported in the hyperglycemic state26. Since most TYPE-II DIABETES n = 138 individuals experience a phase of impaired glucose tolerance Serum Uric Number Percent Mean Min – before progression to diabetes, it is not clear whether raised serum 24,25 Acid of Cases ±SD Max uric acid predicts the risk of type-II diabetes . We investigated mg/dL the association between serum uric acid and risk of diabetes in mg/dL mg/dL the Rotterdam Study, a large population-based, prospective cohort Under 6 10 7.2% 13.3 3 - 16 study among subjects aged 55 years and older. In this study the 6 – 7 44 31.9% ±2.5 mean age was 57.5 ±12.3 years with Male: Female = 1.2: 1. A study from Brazil reported the mean age 63.3 ±8.6 years with Over 7 84 60.9% male: female = 1: 1.4 of patients with type-II diabetes26. another study from Iran reported the mean age of the type-II diabetic patients was 52.45 ±10.11 years27. Overall mean serum uric acid was found 13.3 ±2.5 mg/dL (Min – Max = 3 – 16 mg/dL) in type- II diabetic cases. Majority 60.9% of cases had serum uric acid level > 7 mg/dL. The mean value of serum uric acid was 15.1 ±1.9 mg/dL in men and 11.2 ±3.1 mg/dL in women A study was found that the subjects with FBG >110 mg/dl had mean serum uric acid

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48 Kashif Ali Fazlani et al, (2017) Serum Uric Acid Level in Patients with Diabetes Mellitus Attending a Tertiary Care Hospital. Int J clinical & case. 1:2, 46-50.

5.51±1.14 in men and 3.64±1.14 in women12. In a recent study 5. Johnson RJ, Gaucher EA, Sautin YY, Henderson GN, patients with diabetes Mellitus had serum uric acid level 16.5 Angerhofer AJ, Benner SA. The planetary biology of ascorbate ±5.98 mg/dl13. A study from Peshawar reported mean serum acid and uric acid and their relationship with the epidemic of obesity was 6.07 mg/dl, in this study the average level of serum uric acid and cardiovascular disease. Med Hypotheses. 2008;71:22-31. in female was 5.63 mg/dl and in male patients was 6.6 mg/dl28. A 6. Chen LK, Lin MH, Lai HY, Hwang SJ, Chiou ST. Uric acid: study from Netherlands reported the mean serum acid was 5.5 ±1.4 a surrogate of insulin resistance in older women. Maturitas. mg/dl in type-II diabetic cases29. A Brazilian reported the mean 2008;59:55-61. level of uric acid 6.8 ±1.3 in patients with type-II diabetes. 30 A Iranian study measured the mean serum uric acid concentration 7. Milionis HJ, Kakafika AI, Tsouli SG, Athyros VG, Bairaktari was 4.56 ±1.33 mg/dL (In men was 4.89 ± 1.36 mg/dL 4.30 ±1.24 ET, Seferiadis KI, Elisaf MS. Effects of statin treatment on uric mg/dL in women) 29 In conclusion that SUA level is independently acid homeostasis in patients with primary hyperlipidemia. Am associated with the type-II diabetes. Although few other Heart J. 2004;148:635-40. researchers observed negative association. Ishihara et al.30 studied 8. Lippi G, Montagnana M, Franchini M, Favaloro EJ, Targher the relationship between the urinary excretion of calcium and uric G. The paradoxical relationship between serum uric acid and acid in type-II diabetic patients. They found that in diabetic patients cardiovascular disease. Clinica Chimica Acta. 2008;392:1-7. serume level of uric acid was lower than in normal subjects. Their analysis showed that the diabetic patients had increased fractional 9. Shankar A, Klein BEK, Nieto FJ, Klein R. Association excretion of uric acid. Gonza et al. 105 observed similar finding between serum uric acid level and peripheral arterial disease. in insulin dependant diabetic patients. The association of serum Atherosclerosis. 2008;196:749-55. uric acid with diabetes mellitus has also been explained on the 10. Ruggiero C, Cherubini A, Ble A, Bos AJG, Maggio M, Dixit basis of genetic predisposition. hyperuricemia may result in acute VD et al. Uric acid and inflammatory markers. Eur Heart J. gouty arthritis, nephrolithiasis, and nephropathy. Elevated level of 2006;27:1174-81. serum uric acid with diabetes mellitus may specially give rise to complication like overt nephropathy and stroke.30 11. Strazzullo P, Puig JG. Uric acid and oxidative stress: relative impact on cardiovascular risk. Nutr Metab Cardiovasc Dis. Conclusion 2007;17:409-14. In this study mean serum uric acid was found 13.3 ±2.5 mg/dL (15.1 12. 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