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Medical Progress

Current Concepts of Hyperuricemia

and Gout


* Recent studies have confirmed that gout is an inborn error of metab- olism. It has now become evident that the hyperuricemia associated with gout might occur either due to overproduction of uric acid, underexcre- tion of uric acid or a combination of these processes. Furthermore, pa- tients with excessive purine synthesis may have a specific enzyme defect resulting in altered feedback inhibition of purine synthesis. A neuro- logical disease manifest by mental retardation, choreo-athetosis, aggres- sivebehavior, lip-bitingandself-mutilationandassociatedwithdecidedly

increased purine biosynthesis serves as a prototype of this kind of

disorder. Other defects in regulation of purine biosynthesis have been

postulated but theirexistence notyetconfirmed.

It has been demonstrated that urate crystals which are deposited

from hyperuricemic body fluids set up an acute inflammatory reaction

by means of a variety of chemical mediators. Thus, acute gouty arthritis

is now recognized as an example of "crystal induced" synovitis. The treatment of gout consists of (1) the control of acute gouty

attacks, and (2) the maintenance of normal serum uric acid concentra- tions. This latter may be achieved either with uricosuric drugs or with xanthine oxidase inhibition. With these principles in mind, it is now

possible to avoid many of the severe crippling effects of gout and to

restore the vast majority of gouty patients to useful and productive lives.

ALTHOUGH THE FIRST clinical description of gouty arthritis is attributed to Hippocrates, it has been

onlyduringthe pastdecade thatconcepts regarding

the pathogenesis of hyperuricemia and its relation- ship to gout have been firmly established. Scheele in 1776 isolated uric acid from a urinary calculus

The author is Assistant Professor of Medicine at UCLA School of

Medicine, Los Angeles.

1000 Veteran

This work partially supported

Reprint requests to: Institute of

by U.S.P.H.S. Grant #GM15759.

Chronic Diseases and Rehabilitation,

Avenue, Los Angeles 90024.

and in 1797 Wollaston demonstrated that gouty

tophi contain uric acid. Garrod, in 1876, using

crude methods, demonstrated that the blood of

gouty patients contained excessive quantities of

uric acid and subsequently it was shown that hyper- uricemia was also present in the normal relatives of gouty patients. The younger Garrod in 19311 classified gout as "an inborn error of metabolism" but noted that no enzyme deficiency characteristic of this disease had been found. During the past


decade, however, investigators have provided evi-

dence for a variety of biochemical and physical abnormalities that result in hyperuricemia. Fur- thermore, experimental findings during this period have also provided a framework for the construc- tion of an hypothesis for the mechanisms of the crystal induced synovitis of acute gout. These recent developments and concepts will be reviewed.

Biochemistry of Uric Acid

Properties of Uric Acid

Uric acid (2, 6, 8 trioxypurine) is weakly acidic due to ionization of the hydrogen atoms at position

9 (pKa=5.75) and 3 (pKa-10.3) while the

hydrogen atoms at positions 1 and 7 do not ionize

significantly. Thus at physiologic pH (7.4) uric

acid exists almost entirely in the salt form as a monovalent urate ion.2 Therefore urate is deposited

in tophi as monosodium urate monohydrate3 while due to the more acidic nature of urine, renal calculi are in the form of undissociated uric acid. Uric acid readily forms supersaturated solutions both in plasma and protein free buffer systems.4 This phenomenon greatly hampers the ability to accu-

rately determine solubility of urate in biological


UricAcidAssay The colorimetric assays for urate frequently used in routine clinical laboratories depend upon

the ability of urate to reduce a reagent such as

phosphotungstic acid to a chromagen.5 Since non- urate metabolites of methylated purines (for exam- ple, caffeine or theophylline) and the other oxy- purines (that is, hypoxanthine and xanthine) also reduce phosphotungstic acid, the use of colori- metric assays may give spuriously elevated values in patients ingesting caffeinated beverages, the-

ophylline drugs or the xanthine oxidase inhibitor

ailopurinol. Another error inherent in colorimetric procedures for measuring uric acid results from the need to deproteinize serum with the consequent

coprecipitation of some uric acid.

An enzymatic spectrophotometric method for

measuring urate concentration6 eliminates these

errors. Uric acid may be measured directly in

whole serum by determining the absorbancy at

292 mu at pH 9.4 before and after reaction with the highly specific enzyme uricase which is capable

of converting all the uric acid present to allantoin

and co2. This technique is sufficiently sensitive

to detect microgram quantities of urate with an accuracy of 2 percent. A modification of this

method for the determination of total oxypurines in urine and plasma7 has recently been described.

During the past few years multichannel auto-

analyzers have been adapted to determine serum urate by colorimetric techniques,8 thus allowing hundreds of determinations to be performed daily

with a high degree of accuracy. Because such

multiphasic screening programs are in use in our

hospitals and clinics today, a great number of pa-

tients with unsuspected hyperuricemia are being

detected. The significance of such hyperuricemia

and an approach to this problem will be discussed


Purine Metabolism

Uric acid is truly the end product of purine

metabolism in man since through the process of evolution there has been loss of the enzyme uricase

which is capable of catalyzing the further metab-

olism of uric acid to allantoin and Co2. Hyper-

uricemia, therefore may result from either in- creased absorption of precursor purines, increased

production, decreased excretion or decreased breakdown of uric acid or from some combination

of these mechanisms. Since a purine-free diet results in an average reduction of serum urate of only 1 mg per 100 m19

in gouty subjects and does not correct hyperurice-

mia, it is clear that the hyperuricemia of gout

cannot be attributed to abnormal absorption of

precursor purines. It is likely, however, that an

increased purine load may serve as a mechanism

for the secondary hyperuricemia seen in patients with lymphoproliferative disorders with a rapid

turnover of tumor cellsI0 or with psoriasis where

there is a rapid turnover of the skin.11

Uricolysis in man occurs almost entirely by ac-

tion of intestinal flora upon uric acid entering the

gastrointestinal tract.'2 There is no evidence that

uricolysis is diminished in patients with gout and,

in fact, Sorenson'3 has demonstrated that in gouty patients with reduced renal excretion of uric acid, extra-renal disposal may constitute the chief excre- tory mechanism for uric acid. There is, however, considerable evidence that both increased produc- tion of uric acid and reduced renal excretion of

uric acid play important roles in the pathogenesis

of hyperuricemia, both in primary gout and in hyperuricemia secondary to other causes.

Increased Production of Uric Acid Associated with Gout

Evaluation of Uric Acid Synthesis Uric acid is the end-product of purine metab-

olism. Therefore, in the steady state when urate is not being deposited or mobilized, urate production

is approximately equal to uric acid excretion. Un-

der the standard basal conditions of a purine-free

diet and no medications, the consistent daily urinary

excretion of more than 600 mg of uric acid there-

fore is a good indication that a patient has increased uric acid production. Approximately 25 percent of gouty patients show such an excess in urinary uric acid excretion. This indirect measurement, however, does not adequately reflect uric acid synthesis in patients with impaired renal function.

Uric acid production may be directly assessed by

measuring the incorporation of isotopically labelled glycine into urinary uric acid and correcting such

data for the disposition of the body urate pool as determined by simultaneous administration of iso- topically labelled uric acid. By these techniques

Seegmiller and coworkers9 found that 67 percent

of patients with primary gout had increased uric

acid synthesis. Furthermore careful evaluation of

studies using isotopically labeled compounds has supplied experimental evidence suggesting that

among gouty patients there is no single metabolic

defect in purine metabolism to account for the


Control of Purine Biosynthesis

It has long been proposed that among gouty patients who overproduce uric acid there may be a defect in the feedback control of purine biosyn-

thesis.2 Feedback control of purine biosynthesis

would be expected to be exerted on the first irre-

versible step of purine biosynthesis-that is, the enzymatic reaction of glutamine with 5 phospho- ribosyl-l-pyrophosphate (PRPP) to form 5 phos- phoribosylamine (Chart 1). Suppression of purine

biosynthesis by the addition of preformed purines

either as free bases or ribonucleotides has been demonstrated in cultured mammalian cells,14"l5 bacterial systems'6 and in liver slices.'7"18 An in- creased rate of purine biosynthesis thus could re-

sult from a loss of the sensitivity of the rate con-

trolling enzymes to feedback inhibitors, from a

diminished concentration of the normal end prod- ucts that function as feedback inhibitors, or from

an increase in concentration of one of the sub-

strates available for the rate limiting reaction.

The first evidence of a regulatory mechanism for control of purine biosynthesis in man came from

studies using the purine precursor 4-amino-5- imidazole carboxamide (AIC). Administration of this compound to non-gouty subjects substantially

reduced de novo uric acid synthesis.'9 Subsequent- ly the drug 6-diazo-5-oxy-l-norleucine (DON) was also shown to suppress purine biosynthesis in gouty subjects.20 Toxic side effects, however, have precluded the clinical use of these compounds. Recently there have been exciting new develop-

ments in this area. In 1966 Sorenson2' found that administration of the purine analog azathioprine

(Imuran®g) to three gouty patients inhibited their

excessive purine synthesis, as measured by a de-

crease in the uric acid content of plasma and urine

as well as the glycine-l-C'4 incorporation into uri- nary uric acid. Two normal subjects and one gout

patient who produced normal quantities of uric acid showed no significant suppression of urate production in response to azathioprine treatment. Sorenson thereforeproposed that azathioprine pro-

duced a unique effect in gouty patients who were overproducers of uric acid, thus implying that the regulation of purine synthesis may differ in different

types of gout. Lesch and Nyhan in 1964 at the Johns Hopkins Hospital firstdescribed a familial neurological dis- order consisting of choreoathetosis, spasticity, men-

talretardation, aggressivebehavior and compulsive biting resulting in mutilation of the lips and fin- gers.22 These findings in two young brothers were associated with hyperuricemia, urinary uric acid excretion which was three to six times normal and

incorporation of from 100 to 200 times the normal

amount of glycine-l-C'4 into urinary uric acid. Numerous other cases have subsequently been

described, limited to males and with a striking familial distribution compatible with x-linked inheritance.23 Although the degree of overproduc-

tion of uric acid found in children with the Lesch- Nyhan syndrome was greatly in excess of that encountered in adults with clinical gout, gouty

arthritis has remained a relatively late occurrence

in these children. Gouty nephropathy, however,

was a contributing factor to the death of some of

these patients in early puberty.24

Because of the pronounced excess of uric acid

produced by these children, Seegmiller and co- workers25 compared the effect of azathioprine in two children with Lesch-Nyhan syndrome and two gouty men who were also overproducers of


uric acid. They found that azathioprine suppressed purine synthesis in the two gout patients but did not diminish it in the children. Since the pharma-

cologic action of azathioprine probably results from its degradation to 6-mercaptopurine (6MP) the effect of 6MP on the purine synthesis of fibro- blasts grown in vitro from biopsy specimens of skin obtained from a child with the Lesch-Nyhan syn- drome was compared with its effect on cells grown from normal subjects. It was found that 6MP great- ly inhibited purine biosynthesis in normal cells but had no effect on cells derived from the child

with the neurological disorder. Resistance to the

action of 6MP had previously been described in

mutant mammalian tumor cells26 and leukemic

leukocytes,27 and this phenomenon was ascribed

to a deficiency of the enzyme hypoxanthine-gua-

nine phosphoribosyl transferase (HGPRTase). Therefore, Seegmiller examined the activity of this

enzyme in the fibroblasts grown in vitro as well as

in hemolysates of washed erythrocytes and found that the enzyme activity from cells of affected children was less than 0.05 percent of normal.25 It was thus enticing to attempt to explain both the neurological disease and the increased purine synthesis on the basis of this enzyme defect.

Rosenbloom and coworkers28 demonstrated HG-

PRTase deficiency in the brain and liver as well as

fibroblasts and erythrocytes of these affected chil-

dren. They noted that the absence of this enzyme activity in the basal ganglia where it is normally

of highest activity could be correlated with the fact that the major clinical symptoms are attribut-

able to basal ganglia dysfunction. It was also ob- served that the concentration of oxypurines in the

cerebrospinal fluid (CSF) was four times normal

and was greater than in the plasma, thus suggesting

that the brain also had an increase in purine synthesis. No detectable increase in CSF uric acid concentration was noted. Thus the neurological

dysfunction could be secondary to increased con-

centration of oxypurines or other metabolites of enhanced purine biosynthesis or possibly due to a failure to maintain adequate intracellular con-

centration of certain purine nucleotides necessary for normal brain function.

The existence of a causal relationship between

the deficiency in HGPRTase and accelerated

purine biosynthesis is suggested by the following

evidence: (a) there is an inverse relationship be-

tween the degree of enzyme deficiency and the

rate of purine biosynthesis,25'29 (b) both the en-


MARCH 1969 *




zyme deficiency and either the neurological disease

of children or the gouty arthritis in appropriate kindreds are inherited in an x-linked manner,23,30 (c) all patents with HGPRTase deficiency to date

have been shown to have accelarated purine bio-

synthesis. This relationship between HGPRTase deficiency and accelerated purine biosynthesis was studied in detail, using fibroblast cultures.31 Lack of HGPRT- ase had no detrimental effect on the rate of growth of the fibroblasts. The enzyme deficient fibroblasts had accelerated rates of purine biosynthesis and

elevated levels of PRPP, although the rate of syn-

thesis of this compound was not increased. These cells were sensitive to feedback inhibition of purine

synthesis by nucleotides of adenine and 6 methyl-

mercaptopurine ribonucleoside but the rate of purine synthesis was increased rather than de- creased by hypoxanthine and guanine. Based on these studies it was concluded that the acceleration of purine biosynthesis is probably due to an in-

crease in the activity of phosphoribosyl pyrophos-

phate glutamine amidotransferase, the enzyme cat-

alyzing the first irreversible step of purine biosyn- thesis (Chart 1).









PRPP + Glutamine

,- 5-Phosphoribosyl-l-Amine




C Glycine


iosiuic Acid *


Inosine -Adenosine




Uric Acid













HGPRTase . hypoxanthine -

guanine phosphoribosyltransferase

indicates inhibition

Chart 1.-Pathways

mine, is catalyzed by

of purine metabolism. The first ir-

reversible step of purine biosynthesis, PRPP + gluta-

phosphoribosyl pyrophosphate glu-

tamine amidotransferase.

Abnormalities of Purine Biosynthesis In Patients with Gout

In addition to the complete deficiency of HGP- RTase described in patients with the Lesch-Nyhan

syndrome, Kelly and coworkers described a partial

deficiency of this enzyme in five affected members of two families with gout.29'32 Ten other gouty patients with excessive purine biosynthesis simi- larly studied had normal concentrations of this enzyme.29 These patients with gout and a partial enzyme deficiency not only had some residual enzyme activity but also showed different amounts

of activity depending upon whether hypoxanthine or guanine served as the substrate, suggesting that

the HGPRTase which is present in these patients

may be structurally different from both the normal

enzyme and from other affected patients. Other instances of partial deficiencies of HGPRTase in patients with gout and minimal neurological ab-

normality have been reported33 including a 21-

year-old man who had onset of gout at age 15 and has very low residual HGPRTase activity but nevertheless has only a minimal neurological deficit

and had no evidence of self-mutilation.34

The demonstration of an enzyme defect in patients with primary gout and excessive purine synthesis has indeed confirmed Garrod's original

proposal that gout is "an inborn error of metab-

olism."' Furthermore it affords a possible explana-

tion as to why these patients have excessive purine

biosynthesis35 and abnormal resistance to the sup- pressive effects of azathioprine36 and allopurinol37

on purine production. However, this single enzyme

defect occurs in less than 30 percent of patients with primary gout and excessive purine synthesis

and therefore different metabolic defects are prob-

ably present in these other patients. Rosenbloom

and coworkers38 recently demonstrated decreased

sensitivity to feedback inhibition of purine biosyn- thesis in cultured fibroblasts from two patients with

increased purine production and normal HGPRT-

ase concentrations. They suggested that the first

enzyme of the de novo purine pathway, 5-phos-

phoribosyl-1-pyrophosphateglutamine amidotrans-

ferase (Chart 1), may be abnormal in the gouty

patients and thus less sensitive to feedback inhibi-

tion.39 However, Seegmiller and coworkers,40

studyingsimilarpatients,found normal suppression

of glycine-l-C'4 incorporation into urinary uric

acid following adenine administration, thus sug-

gesting that feedback inhibition is intact. These in- vestigations all provide additional evidence for

heterogeneity of the causes of hyperuricemia, even

in patients with gout and excessive purine biosyn-

thesis and suggest that only within given families may common causes for hyperuricemia be found. Numerous investigations are under way in an at- tempt to delineate additional specific defects in

purine metabolism in patients with increased uric

acid production.

Renal Excretion of Uric Acid A diminished renal excretion of uric acid in gouty patients was suggested as a possible cause of hyperuricemia nearly a century ago. Gutman and Yii4 failed to show significant differences in the

urate/inulin clearance ratios between normal and

gouty subjects. Nugent and Tyler,42 however, showed that six gouty subjects had urate/inulin clearance ratios significantly lower than those of normal subjects made comparably hyperuricemic with ahigh purine diet. This findingwas confirmed

by Seegmiller and coworkers,43 who found a diminished urate/inulin clearance ratio in all five gouty subjects who showed normal uric acid pro- duction, while among patients who produced ex-

cessive amounts of uric acid the urate/inulin clear- ance ratios were identical with those of normal control subjects in whom hyperuricemia was in-

duced by dietary means. Other gouty patients

showed some degree of both overproduction and

diminished renal excretion of uric acid, again sug- gesting the heterogeneity of causes for hyperurice- mia among gouty patients. Diminution in renal

clearance of uric acid may be produced by a variety of chemical substances and drugs. It may account for the hyperuricemia seen after the in- gestion of low doses of salicylates,44 chlorothia-

zides45'46 or an association with the lactic acidemia

of glycogen storage disease47 or the ketoacidosis of diabetes mellitus or starvation.48

The mechanism for the excretion of uric acid by

the kidney was originally thought to consist of complete filtration of uric acid at the glomerulus followed by tubular reabsorption of 90 to 95 per- cent of the filtered load4l without appreciable tubular secretion. However, evidence for tubular

secretion of uric acid now includes: (a) studies of

a patient with hypouricemia in whom urate/inulin

clearance ratios exceed 1: 1,49 (b) induction of clearance ratios of urate to insulin greater than 1:1

by administration of uricosuric drugs during man- nitol diuresis,50 (c) the paradoxical effects of salicylates which causes urate retentionwhen given


in low doses (attributed to inhibition of tubular secretion) and uricosuria when given at high doses (attributed to inhibition of tubular reabsorption).44 Tubular secretion has also been shown to play a role in the renal excretion of the oxypurines (hypoxanthine and xanthine).51 Although the exact sites of tubular secretion have not been

elucidated there is at least some indirect evidence

for competition between uric acid and oxypurines forrenal tubular secretion.51'52 Thus, it is currently believed that uric acid is filtered at the glomerulus, and that the filtered uric acid is completely reabsorbed in the proximal tubules and that excreted uric acid is the result al- most entirely of a tubular secretory process. This concept presumes that urate is entirely filterable and therefore not bound to protein. Evidence sug- gesting that there may, in fact, be some binding of urate to proteins, as discussed below, may neces-

sitate additional alterations in our concept of the mechanisms of renal excretion of uric acid.

Acute Gouty Arthritis

The Inflammatory Reaction

Recent concepts of the mechanisms responsible for attacks of acute gouty arthritis really represent

rediscoveries of early hypotheses proposed by Garrod,53 Freudweiler54 and Roberts.55 Garrod considered acute gouty arthritis to be an inflam-

matory reaction to crystals of sodium urate de-

posited from hyperuricemic body fluids in and about the joints during an acute attack. However, evidence against Garrod's proposals included:

(a) the reported failure of injected urate to give

rise to an inflammatory response, (b) the general- ly painless nature of tophi which were shown to be deposits of urate crystals, (c) the poor correla- tion between acute attacks of gout and the serum

urate concentration, and (d) the paradox whereby

colchicine, which has a remarkable therapeutic effect on acute gouty arthritis, does not alter the

serum urate concentration while uricosuric agents,

which lower the serum urate may, in fact, trigger

acute gouty attacks. Therefore this hypothesis was abandoned, even after Roberts in 189255 found that synovial fluid obtained from patients with acute gouty arthritis was "laden with crystals of

sodium biurate."

The above concepts were reassessed beginning

in 1961 when McCarty and Hollander56 again identified urate crystals in gouty synovial fluid. Additional evidence was obtained when Seegmiller

and coworkers57 showed that intra-articular injec-

tions of microcrystalline monosodium urate mono- hydrate in gouty and non-gouty volunteers pro- duced warmth, swelling and pain indistinguishable from the signs and symptoms of acute gout. Similar injections of an amorphous urate suspension pro- duced little reaction. Independently, Faires and McCarty58 confirmed this work and also produced synovitis in dogs with intra-articular urate injec- tions.

Based on these experimental findings, Seegmilier

and Howell59 proposed the following mechanism for the development of acute gouty arthritis: (a)

there is intra-articular deposition of microcrystal-

line monosodium urate monohydrate from hyper- uricemic body fluids, (b) there develops an acute inflammatory reaction to the crystals with local

infiltration, predominately by granulocytes, which phagocytize the urate crystals, (c) propagation of

the acute inflammatory reaction by continued in- troduction of new crystals possibly due in part to alterations in local factors (such as decreasing pH)

with further decrease in urate solubility.


A key point in this hypothesis is the deposition

of urate crystals from hyperuricemic body fluids and therefore there has been considerable interest

in factors that might be responsible for urate depo-

sition. Since physical chemical properties are of great importance we studied the solubility of uric

acid and sodium urate in serum.4 When uric acid

rather than sodium urate is incubated with serum for one hour and the excess crystals then removed by passing the serum through a millipore filter of 0.22 mu, it was found that a urate concentration in the filtrate of approximately 400 mg per 100 ml could be achieved. Immediately after filtration there was spontaneous crystallization of monoso-

dium urate monohydrate from the supersaturated

solution. Concentrations of urate in solution diminished rapidly at first and then more slowly,

reaching an ultimate concentration of 8.5 mg per

100 ml after about three days' incubation. With lower concentrations 'of uric acid in the serum there was greater stability of these supersaturated solu- tions such that at urate concentrations of approx- imately 50 mg per 100 ml the solutions would be

stable for as long as four days without evidence of spontaneous crystal formation. Only when crystals of sodium urate were added to seed the system was

there precipitation. Therefore we explored the

possibility that sodium urate may exist in super-

saturated solutions in the range of serum urate con- centrations commonly encountered in clinical prac- tice. Serum obtained from gouty and non-gouty

subjects was incubated with crystals of monoso-

dium urate. After two hours' incubation the crystals were filtered off and the concentration of urate in the solution was determined. At initial serum urate values of less than 7 mg per 100 ml, sodium urate went into solution, while at initial values greater than this, urate precipitated from solution during the incubation period. This pro-

vided an in vitro model of the deposition of tophaceous deposits at high serum urate levels and the resolution at low serum urate concentra-

tions. It further illustrated the central importance

of bringing the serum urate concentration of a gouty patient into the normal range for effective management of their disease. It also allowed

some speculation that one of the essential differ-

ences between the gouty patient and his equally hyperuricemic brother could be the chance forma-

tion of the first crystal of sodium urate.

Urate Binding to Plasma Proteins

In addition to the primarily physical chemical considerations there has also been increasing in- terest that other factors might be responsible for increased uric acid deposition seen in patients with gouty arthritis. It has been noted, for example, that in certain conditions associated with extremely

high serum urate concentrations, such as lympho-

proliferative disorders and chronic renal disease,

acute gouty attacks are infrequent, while patients

with primary gout have only modest elevations of

the serum urate. This might then suggest other factors, peculiar to patients with gout, that would

afford an increased propensity to urate deposition.

One prime possibility is that urate in biological

fluids exists in combination with other substances which might help to solubilize the urate.

The possibility that urate is bound to plasma pro- teins has been extensively investigated in the past with conflicting results. Recently, however, Alvs-

aker, using the methods of gel filtration and im- munoelectrophoresis followed by autoradiography,

demonstrated a reversibleinteractionbetween urate

and albumin,60 low density beta lipoprotein, beta

2-macroglobulin and an alpha 1-alpha 2 globulin.61 Furthermore, he noted the absence of this alpha 1-alpha 2 globulin in seven out of eight patients with primary gout. He therefore concluded that

the alpha 1-alpha 2 globulin serves as a specific

transport protein for uric acid in blood, is absent in patients with primary gout, and is in some way

associated with the pathogenesis of this disease. Subsequently, Alvsaker noted that low concentra- tions of this urate-binding protein are present in gouty patients and has sugg