Study On Levels Of Serum IL-6,TGF-β1,Cys-C,Urine L-FABP In Male Hyperuricemic Patients And Gout Group After Febuxostat Treatment

Background and ObjectionA large number of epidemiological investigation showed hyperuricemia (HUA) and gout incidence increased year by year, after the second metabolic disease of diabetes, increased health care costs, the serious influence the quality of human life. Many retrospective and prospective observational study to evaluate the relationship between UA and chronic kidney disease (CKD). Most of the data support for UA is result in renal fibrosis, cause kidney disease or the original progress of risk factors for chronic kidney disease (CKD). In recent years, some clinical intervention study further support the role of UA. Uric acid and xanthine oxidase (XO) by inducing inflammation, endothelial dysfunction, oxidative stress and activation of the RAS pathway leading to renal fibrosis and renal disease progression.. Besides, hyperuricemia induces alterations in renal hemodynamics via afferent arteriolopathy and contributes to the onset and progression of kidney fibrosis. Evidence from animal studies show xanthine oxidase inhibitors may prevent kidney damage via lowering uric acid and/or inhibiting xanthine oxidase. With regard to the animal models in this research field,the uricase inhibitor OA-induced hyperuricemic rat model was mainly used during the initial several years and all of the studies used allopurinol as a XO inhibitor. However, recently in basic research,febuxostat has largely replaced allopurinol as a XO inhibitor,and several animal studies have shown various beneficial effects of febuxostat in reducing inflammation, oxidative stress, and kidney fibrosis.HUA, is ascribable to uric acid overproduction and/or underexcretion, defined as a serum urate level exceeding the limit of solubility, mirrors supersaturation of the extracellular fluid with urate, and predisposes affected subjects to gout,which is characterized by the tissue deposition of monosodium urate crystals, although it is a necessary but not a substantial factor for the development of the disease. With the development of economy continuously, people’s substance living standard improve distinguished,expansion with unhealthy modern life style, which cause people daily intake high purine diet and might increase the risk of HUA and gout. Alarming increases in the prevalence of HUA and gout,which incidence tends to be younger,men higher than women,coastal higher than inland. Statistics from endocrine society showed that morbidity/prevalence of HUA was ten percentage approximately,which total about 1.2 hundred million and almost 17 milions who ever occurred gout flare. Recent decades, a growing number of evidence has suggested a role of UA in the causation or progression of cardiovascular and chronic renal disease(CKD). Iseki et al screened 48,177 Japanese adults and calculated the cumulative incidence of endstage renal disease (ESRD) according to quartiles of baseline serum urate levels for each sex. The researchers concluded that hyperuricemia was associated with a greater risk of ESRD even after adjustment for comorbidities. They also suggested that lowering urate levels to within "normal range" may reduce the population burden of ESRD.Tomita et al investigated the relationship between urate levels and various health hazards in a prospective cohort study that followed 49,413 male Japanese railroad workers aged 25 to 60 years for an average of 5.4 years. They found a strong association between serum urate level and renal failure, even when adjusted for covariate effects, with high urate levels (> 8.5 mg/dL) conferring a greater than eightfold increase in the risk of renal failure relative to moderate urate levels (5.0 to 6.4 mg/dL). Dong-Hyuk Jung et al investigated association of renal manifestations with serum uric acid in korean adults with normal uric acid levels suggests that uric acid appears to contribute to renal impairment in subjects with normal serum level of uric acid.Young Kim at el. After taking into account the results of all important experimental studies about UA and CKD, UA and XO may contribute to kidney fibrosis mainly by inducing inflammation, endothelial dysfunction, oxidative stress, and activation of RAS. It is conceivable that uric acid could elicit inflammation in kidney,which plays a major role in the pathophysiologic features of kidney injury. Inflammatory cells release pro-inflammatory chemokines and cytokines, which thereby lead to a self-aggravation of primary insults. In addition, production of pro-fibrotic cytokines may promote tissue fibrosis by activating matrixproducing effecter cells, such as tubular cells and fibroblasts. Xiaoliang Z et al cell experiment suggested that IL-6 enhances TGF-β1 (Smad-dependent) Signaling,Activation of the Smad signaling pathway,which is dose-dependently strengthens TGF-β1 fibrosis activity. Chi-Chang Huang et al animal experiment found that hyperuricemia induced IL-6 expression and downregulated p-STAT3 expression dose-dependently, which suggests that the IL-6/STAT3 signaling pathway participated in the hyperuricemia-induced development of AKI. Inflammatory factor IL-6 enhance TGF-β1’s effect on promoting fibrosis is one of the mechanisms of hyperuricemia cause kidney fibrosis, did not see the relevant clinical research literature published at present.Hyperuricemia significantly induced nephron injury both in the glomerulus and tubules. Rencent years, a lot findings support Cys-C to be a marker with both high sensibility and specificity for assessing early renal function,which has good correlation with creanin and GFR in varied renal diseases. L-FABP is expressed in renal proximal tubular cells and is assumed to be shed into urine in response to hypoxia caused by decreased peritubular capillary blood flow.Therefore urinary L-FABP may be a useful clinical biomarker for monitoring chronic glomerular disease, and reflect the clinical prognosis of CKD. Leon Holzscheiter 2014 clinic experiment showed L-FABP has a high correlation with al-microglobulin (r=0.76, p<0.01) and injuries of the renal tubular system Urinary L-FABP (uL-FABP) levels are seemingly determined by proximal tubule injury.An increasing number of epidemiologic and experimental evedence suggested that UA lowering therapy plays a positive role in reducing incidence and slow down progression of renal disease. A novel urate-lowering drug, febuxostat, is a potent nonpurine selective inhibitor of XO, and it inhibits both the reduced and oxidized forms of the enzyme in contrast to allopurinol that inhibits the reduced form of the enzyme only Many experimental studies have shown that XO inhibitors may prevent kidney damage by lowering UA and inhibiting XO. However, recently in basic research,febuxostat has largely replaced allopurinol as a XO inhibitor,and several animal studies have shown various beneficial effects of febuxostat in reducing inflammation, oxidative stress, and kidney fibrosis.Know more about HUA associated renal injury contributes considerable significant to medicine research and early interference of disease.Our research investigated the levels of serum IL-6、TGF-β1、Cys-C and uL-FABP in hyperuricemic patients before and after febuxostat treatment and evaluated the effect of febuxostat in lowering uric acid.Methods1. Study design and participants1.1 ParticipantsSubjects were selected in our hospital endocrinology clinic HUA male patients in April 2014 to April 2015.Total 110 subjects were erolled in our study which were divided into symptomless hyperuricemia group(the sHUA group) and Gout group(the G group).The total of subjects in the sHUA group is 60, and the average age is 47.3±12.8 years.The total of subjects in the G group is 50, and the average age is 47.7± 13.0 years.Additional,selected 60 health male in the corresponding time period as control group (NC). The average age of NC group is 49.7±14.2.1.2 Study designAccording to expert consensus from Chinese Society of endocrinology on sHUA and gout treatment, febuxostat tablet(from Jiangsu wanbang biochemical pharmaceutical co., LTD) is selected for UA lowering treatment. In the G group,48 subjets take in 40mg once daily. Telephone follow-up once a week record adverse reactions during the test.If gout flare occur,add colchicine and/or Nonsteroidal Antiinflammatory Drugs, NSAIDs for symptomatic treatment.2. Experimental Methods2.1 Specimen CollectionAfter 10 hours of fasting, all subjects underwent venous blood drawing of the next morning using blood-collection tube. After standing for 30min, they were placed into the centrifuge and centrifuged for 5min at 3000r/min. Separation of serum and urine in sterile EP tube frozen in-80℃ saved for later use.2.2 Experimental MethodsHeight, weight, BMI, WC, BC, W/B, TC, HDL-C, LDL-C, TG, ALT,β2-MG, hsC-RP, Scr, BUN, TGF-β1,IL-6, Cys-C, uL-FABP were measured at baseline and at the end of the trial. Serum TGF-β1,IL-6, Cys-C and uL-FABP level was measured by ELISA method. Methods according to kit instructions.Experimental methods according to the kit manual operation. According to the absorbance value of specimens,were calculated for each sample, the corresponding TGF-β1,IL-6,Cys-C and uL-FABP levels. GFR was calculated by formula of MDRD(eGFR=186× (Scr/88.4)-1.154×(Age)-0.203.2.3 Judging adverse reactionsGout flare,dizzy,tingle,blurred,peliosis,palmus,chest,distress,nausea, diarrhea, abdominal pain,et al. reaction were recorded during the study.2.4 Statistical MethodsAll statistical analyses were performed according to intention-to-treat, using IBM SPSS version 20.0. Descriptive characteristics are expressed as mean±SD; One way ANVOA were performed to assess three groups difference, multiple samples of the two compare with SNK-q test; Paired two-tailed t tests were performed using subjects before and after febuxotat treatment. Non-normal distribution data using the median and interquartile spacing M(25%,75%), comparing multiple samples using Kruskal Wallis method, multiple samples of the two compare with Nemenyi method, before and after treatment with Sighed rank test method. Spearman for corresponding analysis.The have statistical differences (P<0.05).Results1. The characteristics among three groupsThere is no statistical difference on age, WC, DBP, TC, LDL-C, ALT, P2-MG, BUN among three groups(F= 0.456,2.073,3.167,1.286,0.299,3.038,0.299,3.038; P= 0.456,2.073,3.167,1.286,0.299,3.038,0.299,3.038).1.1 Comparison of BML W/B, TG, HDL-C, SBP, FBG, HbAl c.There are significant difference on BMI, W/B, TG, HDL-C, SBP, HbAlc, FBG among three groups (F=5.605、9.446、9.243、31.08、9.331、7.142、6.401,P=0.002、 0.000、0.000、0.000、0.011、0.01、0.002). BMI, SBP in G group higher than NC group; W/B in G group higher than sHUA and NC group; TG, FBG, HbAlc in G and sHUA group higher than NC group; HDL-C in G and sHUA group lower than NC group.1.2 Comparison of SUA, Scr, GFRThere are significant difference on SUA, Scr, GFR among three groups (F=140、9.199.4.971;P=0.000、0.002、0.027). SUA in G and sHUA group higher than NC group; Scr in G group higher than NC group; GFR in G group lower than NC group. There are no significant difference on the rest (P>0.05)1.3 Comparison of TGF-p 1, IL-6, hsC-RP, Cys-C, uL-FABPThere are significant difference on TGF-β1、IL-6、hsC-RP、Cys-C、uL-FABP among three groups(P<0.05). TGF-β1 in G and sHUA group higher than NC group; IL-6. Cys-C、uL-FABP in G group higher than sHUA group, and sHUA higher than NC group; hsC-RP in G group higher than sHUA and NC group.There are no significant difference on the rest.2. The characteristics before and after febuxostat therapyA total of 48 subjects were enrolled in febuxostat therapy study. Of these,46 completed the treatment study,There were 2 patients who did not complete the study because of personal reason, The characteristics of the patients among 46 subjects who accepted UA-lowering treatment were not significantly different after treatment of 12 weeks. There were 3 cases who occurred once gout flare in first two weeks and 2 cases occurred twice gout flare in the first month. Colchicine and/or NSAIDs for symptomatic treatment is effective.2.1 Comparison of biochemical indicatorsThere are significant difference on TG, SUA, hsC-RP between before and after febucoxtat treatment(P<0.05). There are no significant difference on Scr, GFR, et al. rest indicators. TG is lower (0.34±0.26)mmol/L, (t=1 1.37.8.65,P<0.05); SUA is lower (194±57.7) μmol/L, (t=16.604,P<0.05); Scr is lower 4.6±4.3μmol/L, (t=1.153,P>0.05); GFR is higher 2.5±3.4 ml/(min-1.73 m2),(t=1.75, P>0.05).2.2 Comparison of TGF-β1, IL-6, Cys-C, uL-FABPThere are significant difference on TGF-β1、IL-6、Cys-C. uL-FABP between before and after febucoxtat treatment(P<0.05).3. Correlation analysisIL-6 was positively correlated with SUA, Scr, TGF-β1,Cys-C, hsC-RP (r=0.466、 0.410,0.360,0.282,0.142,P<0.05) and negatively correlated with GFR(r=-383,P=0.000). TGF-β1 was positively correlated with SUA, uL-FABP (r=0.266,0.169,P=0.014,0.028) and negatively correlated with HDL-C(r=-0.233,P=0.032). Cys-C was positively correlated with uL-FABP, Scr, Age (r=0.227,0.481,0.395,P=0.027,0.000,0.001) and negatively correlated with GFR (r=-0.457,P=0.000); uL-FABPwas positively correlated with Scr, p2-MG(r=0.128, 0.273,P=0.042,0.005) and negatively correlated with GFR (r=-0.216,P=0.017)4. SaftyThere were no serious adverse reaction exit during febuxostat therapy.There were 3 cases with gout flare reaction once in the first two weeks and 2 cases with gout flare reaction twice in the first month during the treatment period. Colchicine and/or NSAIDs for symptomatic treatment is effective.Conclusion1. Hyperuricemic patients are along with micro-inflammatory based on inflammatoly chemokine IL-6 in G and sHUA group higher than NC group, hsC-RP in G group higher than NC group.2. BMI in G group higher than NC group, W/B in G group higher than sHUA and NC group suggested that obese and overweight people,especially abdominal obesity, easier merger of gout than normal volunteer.3. Hyperuricemia leaded to renal injury both in glomerulus and tubules in the light of Cys-C,uL-FABP in hyperuricemic patients higher than healthy people.4. Hyperuricemic patients’pro-fibrosis sytokine TGF-β1 higher than NC group, which suggests that SUA plays a role of causing fibrosis in renal injury.5. Febuxostat has great intention in lowering SUA and inhibiting pro-inflammation chemokines IL-6 and hsC-RP, and pro-fibrosis cytokine TGF-β1 caused by HUA.6. Cys-C and uL-FABP lower after therapy, which suggests that febuxostat can improve renal injury HUA caused.7. Serum Cys-C was negatively correlated with GFR (r=-0.537), so it is suggested to be as a new good marker for early hyperuricemic renal injury.