What multiple Mendelian randomization approaches reveal about obesity and gout

Background/Objectives: Gout is a painful arthritic disease. A robust canon of observational literature suggests strong relationships between obesity, high urate levels, and gout. But findings from observational studies can be fraught with confounding and reverse causation. They can conflict with findings from Mendelian randomization (MR), designed to tackle these biases. We aimed to determine whether the relationships between obesity, higher urate levels, and gout were causal using multiple MR approaches, including an investigation of how other closely related traits, LDL, HDL cholesterol, and triglyceride levels fit into the picture. Subjects/Methods: Summary results from genome-wide association studies of the five above-mentioned traits were extracted and used to perform two-sample (univariable, multivariable, and two-step) MR and MR mediation analysis. Results Obesity increased urate (beta=0.127; 95% CI=0.098, 0.157; P-value=1.2E-17) and triglyceride levels (beta=0.082; 95% CI=0.065, 0.099; P-value=1.2E-21) and decreased HDL cholesterol levels (beta=-0.083; 95% CI=-0.101, -0.065; P-value=2.5E-19). Higher triglyceride levels increased urate levels (beta=0.198; 95% CI=0.146, 0.251; P-value=8.9E-14) and higher HDL levels decreased them (beta=-0.109; 95% CI=-0.148, -0.071; P-value=2.7E-08). Higher urate levels (OR=1.030; 95% CI=1.028, 1.032; P-value=1.1E-130) and obesity caused gout (OR=1.003; 95% CI=1.001, 1.004; P-value=1.3E-04). The mediation MR of obesity on gout with urate levels as a mediator revealed, however, that essentially all of the effect of obesity on gout is mediated through urate. The impact of obesity on LDL cholesterol was null (beta=-0.011; 95% CI=-0.030, 0.008; P-value=2.6E-01), thus it was not included in the multivariable MR. The multivariable MR of obesity, HDL cholesterol, and triglycerides on urate levels revealed that obesity has an effect on urate levels even when accounting for HDL cholesterol and triglyceride levels. Conclusions: Obesity impacts gout indirectly by influencing urate levels and possibly other traits, such as triglycerides, that increase urate levels. Obesity's impact on urate is exacerbated by its apparent ability to decrease HDL cholesterol.