Clinical Utility Of Serum Uric Acid For Screening, Risk Stratification, And Prediction Of Metabolic Syndrome In Adults: A Systematic Review

Abstract

Background: Serum uric acid (SUA) has evolved from a simple marker of gout to a central metabolic mediator and a robust predictor of cardiometabolic risk. This systematic review assesses the clinical utility of SUA for screening, risk stratification, and predicting metabolic syndrome (MetS) in adults.

Methods: A comprehensive analysis was conducted on primary research articles, including data from large-scale national surveys (e.g., KNHANES, NHANES), prospective longitudinal cohort studies (e.g., CHIEF, Tromsø Study), and community-based cross-sectional investigations. The evidence from diverse global populations, including cohorts from Taiwan, China, Korea, South Asia, Brazil, and Europe, was synthesized to evaluate the association between SUA and MetS, identify optimal screening thresholds, and assess its predictive and prognostic value across different age groups and sexes.

Results: Elevated SUA was consistently associated with an increased risk of incident MetS and remained predictive even within the upper normal range, with optimal thresholds of approximately 4.9 mg/dL in women and 6.3 mg/dL in men. The diagnostic performance of SUA was greater in women (AUC ≈0.77) than in men (AUC ≈0.66), and its predictive power is most robust during young adulthood. Beyond screening, the triglyceride-glucose (TyG) index and SUA/creatinine ratio enhanced cardiovascular risk stratification, while SUA demonstrated high diagnostic accuracy for metabolic dysfunction-associated steatotic liver disease (MASLD). A distinct "diabetes paradox" was also observed, with SUA levels peaking during prediabetes and declining after the onset of overt diabetes.

Conclusion: Current evidence supports SUA as a simple, inexpensive, and clinically useful biomarker for the screening, risk stratification, and prediction of MetS. The application of sex-specific thresholds and integration with complementary biomarkers such as the TyG index and SUA/creatinine ratio may improve early identification of high-risk individuals. Future research must prioritise large-scale randomized controlled trials to establish the definitive therapeutic role of urate-lowering therapies in managing metabolic disease.