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Hyperuricemia Workup

  • Author: Yasir Qazi, MD; Chief Editor: Vecihi Batuman, MD, FACP, FASN  more...
Updated: Feb 22, 2016

Laboratory Studies

Laboratory studies may include the following:

  • Serum uric acid
  • Complete blood cell count (CBC): Values may be abnormal in patients with hemolytic anemia, hematologic malignancies, or lead poisoning.
  • Electrolytes, BUN, and serum creatinine values: These are abnormal in patients with acidosis or renal disease.
  • Liver function tests: These are part of the general workup for patients with a possible malignancy or metabolic disorders; in addition, the results are useful as a baseline if allopurinol is used for treatment
  • Serum glucose level: This may be abnormal in patients with diabetes or glycogen storage diseases.
  • Lipid profile: Results are abnormal in those with dyslipidemia.
  • Calcium and phosphate levels: This measurement is needed for the workup of hyperparathyroidism, sarcoidosis, myeloma, and renal disease.
  • Thyroid-stimulating hormone level: Obtain this value to help rule out hypothyroidism.
  • Urinary uric acid excretion
  • Fractional excretion of urate on a low-purine diet
  • Spot urine ratio of uric acid to creatinine

Urinary uric acid secretion

If uric acid levels are found to be persistently elevated, an estimation of total uric acid excretion may be needed. The estimation of uric acid excretion is recommended in young males who are hyperuricemic, females who are premenopausal, people with a serum uric acid value greater than 11 mg/dL, and patients with gout.

One protocol recommends obtaining two 24-hour urine collections for creatinine clearance and uric acid excretion. The first collection is performed while patients are on their usual diet and alcohol intake. At the end of the first 24-hour collection, serum creatinine and urate levels are checked for an estimation of the creatinine clearance. The patient then goes on a low-purine, alcohol-free diet for 6 days, with a repeat 24-hour urine collection performed on the last day, followed by a serum creatinine and uric acid evaluation.

Depending on the 24-hour urine uric acid levels before the purine-restricted diet and after the purine-restricted diet, patients who are hyperuricemic can be categorized into the following three groups:

  • High-purine intake - Prediet value greater than 6 mmol/d, postdiet value less than 4 mmol/d
  • Overproducers - Prediet value greater than 6 mmol/d, postdiet value greater than 4.5 mmol/d
  • Underexcretors - Prediet value less than 6 mmol/d, postdiet value less than 2 mmol/d

Fractional excretion of urate on a low-purine diet

This test should be used to investigate the degree of underexcretion in patients with hyperuricemia or gout in patients for whom the cause cannot be determined. The fractional excretion of urate is calculated by the following formula:

Fractional excretion of urate = [(urine uric acid)×(serum creatinine)×(100%)]÷[(serum uric acid)×(urine creatinine)]

The reference intervals for patients on a low-purine diet and normal renal function are as follows:

  • Males - 7-9.5%
  • Females - 10-14%
  • Children - 15-22%

Values less than the lower limits of the reference range indicate underexcretion. The formula also circumvents any inaccuracy that may have occurred during urine collection.

Spot urine ratio of uric acid to creatinine 

If a 24-hour urine collection is not possible, measure the ratio of uric acid to creatinine from a spot urine collection. A ratio greater than 0.8 indicates overproduction.

The ratio also helps differentiate acute uric acid nephropathy from the hyperuricemia that occurs secondary to renal failure. The ratio is greater than 0.9 in acute uric acid nephropathy and usually less than 0.7 in hyperuricemia secondary to renal insufficiency.


Imaging Studies

In patients with gout, radiographs may reveal evidence of joint swelling and subcortical cysts. In patients with hyperuricemia and renal disease, a renal sonogram is an important tool for kidney evaluation. Images from this study also may reveal the presence of uric acid stones.



Joint aspiration may be important in the diagnosis of acute gouty arthritis, in which uric acid crystals are found to be negatively birefringent under polarized microscopy.

Contributor Information and Disclosures

Yasir Qazi, MD Assistant Professor of Medicine, Division of Nephrology, University of Southern California at Keck School of Medicine

Yasir Qazi, MD is a member of the following medical societies: American Society of Nephrology

Disclosure: Nothing to disclose.


James W Lohr, MD Professor, Department of Internal Medicine, Division of Nephrology, Fellowship Program Director, University of Buffalo State University of New York School of Medicine and Biomedical Sciences

James W Lohr, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Society of Nephrology, Central Society for Clinical and Translational Research

Disclosure: Partner received salary from Alexion for employment.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

George R Aronoff, MD Director, Professor, Departments of Internal Medicine and Pharmacology, Section of Nephrology, Kidney Disease Program, University of Louisville School of Medicine

George R Aronoff, MD is a member of the following medical societies: American Federation for Medical Research, American Society of Nephrology, Kentucky Medical Association, National Kidney Foundation

Disclosure: Nothing to disclose.

Chief Editor

Vecihi Batuman, MD, FACP, FASN Huberwald Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Renal Section, Southeast Louisiana Veterans Health Care System

Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, International Society of Nephrology

Disclosure: Nothing to disclose.

Additional Contributors

James H Sondheimer, MD, FACP, FASN Associate Professor of Medicine, Wayne State University School of Medicine; Medical Director of Hemodialysis, Harper University Hospital at Detroit Medical Center; Medical Director, DaVita Greenview Dialysis (Southfield)

James H Sondheimer, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Nephrology

Disclosure: Receive dialysis unit medical director fee (as independ ent contractor) for: DaVita .

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