PREVALENCE OF HYPERURICEMIA AMONG PEOPLE OF MORANG DISTRICT OF NEPAL

Hyperuricemia refers to an elevation in the serum uric acid concentration. The blood levels of uric acid are a function of the balance between the breakdown of purines & the rate of uric acid excretion. Theoretically, alterations in this balance many account for hyperuricemia. Prolonged hyperuricemia often associated with gout, is an important risk factor for damaged joints. The present study is undertaken with the aim to find out the prevalence of hyperuricemia by age & sex, to establish the statistically significant correlation between serum creatinine & triglyceride concentration with uric acid concentration & to study the relation between alcohol drinking & hyperuricemia in Morang District, by routine health examinations in the out Patients Department (OPD) of Nobel Medical College, Biratnagar from January 2012 to January 2013. The study reveals that 28.57% (male – 30.06%., female -26.61%) of patients have been suffering from hyperuricemia. It indirectly indicates hyperuricemia is very frequent in developing country like Nepal. The present study denoted that hyperuricemia is directly related to alcohol consumption in both male & female.


Introduction
Hippocrates, in the fifth century B.C, recognized the distinctive clinical features of gouty arthrilitis, which he inscribed in the oldest recorded medical text 1 .The term gout was given by de Vielehardouin in the 13 th century. 2 Uric acid was first isolated from urine by Karl Wilhelem Scheele in 1776 3 .In 1907, Emil Fisher established uric acid to be a purine compound. 4The British physician Alfred Baring Garrod demonstracted by the murexide test in increased amount of uric acid in the blood of gouty subjects. 5He also recognized asymptomatic hyperuricemia, the cause and effect relationship of urate deposition and gouty inflammation, the implication of impaired renal function in gout, the relation of hyperuricemia to gout and treatment changes in urate levels preceding gouty attacks.Uric acid is the final product of purine metabolism in human beings.Unlike allantoin, the more soluble end product found in lower animals, uric acid is a poorly soluble, end product of purine metabolism in humans.Humans have higher levels of uric acid because of a deficiency of the hepatic enzyme, uricase, and a lower fractional excretion of uric acid.Approximately, two thirds of total body urate is produced endogenously, while the remaining one third is accounted for by dietary purines.About 70% of the urate produced daily is excreted by kidneys, while the rest is eliminated by the intestines.
Hyperuricemia refers to an elevation in the serum uric acid concentration.The blood levels of uric acid are a function of the balance between the breakdown of purines and the rate of uric acid excretion.Theoretically, alterations in this balance may account for hyperuricemia, although clinically defective elimination accounts for most cases of hyperuricemia.
Prolonged hyperuricemia often associated with gout, is an important risk factor for damaged joints. 6Hyperuricemia has been shown to be associated with several components of metabolic syndrome (Mets) and investigators have postulated that increased concentrations of uric acid may be another important component of the syndrome. 7[10][11] Hyperuricemia is diagnosed in 5-30% of the general population, although the prevalence is higher among some ethnic groups (e.g, Japanese) and appears to be increasing worldwide. 12Serum uric acid concentrations are known to increase with age and are further increased after menopause in women. 13onsidering current increses in the incidence and prevalence of obesity and Mets worldwide, as well as emerging evidence documenting associations between hyperuricemia and cardiovascular complications further investigations are required.
Acheson and Chan 14 have expressed the situation well by stating."The associates of a high uric acid are the associates of plenty."On the other hands, with rapid economic development, possibility of improved nutrition and promotion of successful health, life expectancy has been prolonged and the elderly population has increased this has true in Morang, a district of Nepal also.Among common disorders of elderly, high serum uric acid levels are found to be directly correlated to hypertension, heart disease, diabetes, kidney disease, dietary habits and nutrition.
Traditionallly, they eat foods that are high in purine such as red meat, beans, cabbage, cauliflower, alcohol and so on.
Little information however exists concerning the prevalence and epidemiological charateristics of hyperuricemia in Nepal.Therefore, the present study is to find out the prevalence of hyperuricemia among Nepali community by routine health examinations in the out patients Department (OPD) of Nobel Medical College, Biratnagar.

Material & Methods
This study was conducted from January 2012 to January 2013 in Nobel Medical College, Biratnagar, Nepal.In course of study, 287 patients wer sent for the investigation of serum uric acid from different.Out Patients Department (OPD) of this Hospital.These patients were selected for the study.History and clinical examination records of selected patients were collected.Selected patients were called on next morning in order to collect fasting blood samples.Median cubital vein of the forearm was used for venipuncture.
The age, sex, alcohol habit and all the biochemical parameters were recorded in predesigned close end Proformal.Later on all the information was entered in a computer programmed.Mean & standard deviation was calculated by excel programmed.The following tests were carried out in the clinical biochemistry laboratory.Al the necessary quality control measures were applied.Measurement of these parameters has been done on Semi-autoanalyzer.

Results
The study was carried out at Department of Biochemisty, Nobel Medical College, Biratnagar.The subjects were taken from Out Patients Department (OPD) of this hospital.
The study was carried out among the patient attending from January 2012 to January 2013.The total no. of case was 287.

Series1
Chart No. 4.3 Above table shows that an average uric acid level in male was 6.67±1.58 and for the female was 5.39±1.53.The prevalence rate of Hyperuricemia for male was 30.06% and for the female 26.61%.
This table showed that hyperuricemia is related to the intake of alcohol.

Discussion
Serum uric acid has been shown to be related to risk of hypertension , cardiovascular diseases and type 2 diabetes in clinical and epidemiological studies, in addition to gout, which is specific disease caused by high uric acid [130][131][132][133] .This study has tried to know the prevalence of hyperuricemia, Morang District and also to know the important risk factors that elevate the serum uric acid levels.
The main observations of the present study are the followings:-• Firstly the prevalence of the hgyperuricemia was high in Male.
• Secondly, a particularly strong association was found between serum uric acid levels and triglycerides.• Thirdly, a significant relationship between serum uric acid and creatinine was found.
The present study has revealed that the prevalence of hyperuricemia among the patients, attending Nobel Medical College was 28.33% (male 30.06%, female 26.61%).This value is quite higher than reported for several other populations earlier.The 10.6% prevalence of hyperuricemia was noted among the men and women, 56 while Nagahama and colleagues 55 reported that 24.4% were diagnosed hyperuricemia in Japan.In Saudi men and women, hyperuricemia is estimated to 8.4%. 58In European countries and United States; hyperuricemia is estimated to 2 to 18% of the total population 134 .
According to my studies, it was found that serum uric acid levels were higher in men (6.37±1.58mg/dl)than in women (5.39±1.53mg/dl)which is similar to other observations.Studies in Europe and the United states have shown that average uric acid value in male is around 5.0 to 5.7 mg/dl and slightly lower in female at 3.7 to 5.0 mg/dl 135 133,136 In present study serum uric acid concentration was statistically significant and positively correlated with serum triglyceride concentration (p<0.0001) and serum creatinine concentration (p<0.0001).These associations were generally similar to those reported by other investigators. 91,92,134,135 Thpotential mechanisms related hyperuricemia to fasting hypertriglyceridemia are unknown.It has been speculated to be due to an increase in NADPH requirement for de novo fatty acid synthesis in obese men.With increased NADPH, uric acid producton is enhanced, and this might increase serum uric acid level 137 .
My observation showed that alcohol drinking was found to be closely related to hyperuricemia.Alcohol is useful for excretion of uric acid and that the excretion rate of uric acid by the kidney does not decline because of drinking.Alcohol consumption causes accelerated hepatic break down of ATP and increase urate production and also may cause hyperlacticacidemia which competitively blocks the uric acid secretion. 121The higher purine content in some alcoholic beverage such as beer may be a factor that increases the uric acid level in blood. 122 present study it was not found statically significant relationship between fasting blood sugar and hyperuricemia.Many studies showed similar patterns of finding. 138,139e appeared to be related to hyperuricemia in present study, which was consistent and adjacent with other studies.As the present study showed average age for hyperuricemia was 48.04 ±18.18 with respect to average age of normal uric acid patients 41.39±14.11.However, some Asian studies age was reported as risk factors for hyperuricemia in women but in men hyperuricemia was found to decrease with age. 57,140This study also emphasized the prevalence of hyperuricemia increased with age (table no.4.4).Increasing patterns of serum uric acid level with age might be due to impaired renal function, use of diuretics, hypertension as common in elderly patients 34,117,118 .
Although many risks factors that could affect the level of uric acid; unfortunately I did not collect detailed information of other determinations of hyperuricemia.

Table No . 4.6 Single Variable Analysis of Hyperuricemia and Drinking Alcohol.
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