Urinary Uric Acid and Creatinine Ratio as a Marker of Perinatal Asphyxia

Document Type : Original Article


Department of Pediatrics, Dr. S N Medical College, Jodhpur, Rajasthan, India


Background: Prediction of the outcome of perinatal asphyxia (PA) is important but formidable. Apgar score has a limited role in predicting the outcome. Urinary uric acid and creatinine ratio (UA/Cr) is an early, noninvasive, and cheap biomarker of PA which may predict its morbidity. This study aimed to determine the urinary UA/Cr in neonates with PA, compare it with UA/Cr in non-asphyxiated neonates, and derive the optimum cut-off value of this ratio to label PA.
Methods: This observational cross-sectional study was carried out on 100 term neonates appropriate for gestational age (AGA) with PA (cases) and 100 non-asphyxiated term AGA babies (controls). Urine samples were collected within 24 h of life; moreover, uric acid and creatinine levels were determined by an auto-analyzer.
Results: The mean urinary UA/Cr ratio was significantly higher in the cases, compared to the controls (3.41±0.68 vs. 1.99±0.23) (P<0.0001). The cut-off value of this ratio to label PA was>2.5 with sensitivity, specificity, positive predictive value, and negative predictive value of 98%. Urinary UA/Cr ratio and cord blood pH were significantly correlated with each other (correlation coefficient r=-0.8951, P<0.001). Moreover, the urinary UA/Cr ratio and 5-min Apgar score were also significantly correlated with each other (r=-0.8806, P<0.001).
Conclusion: Urinary UA/Cr ratio is a non-invasive, cheap, and reliable marker for PA with good predictive value in this study.


  1. World Health Statistics. 2013.
  2. Porter KB, O'brien WF, Benoit R. Comparison of cord purine metabolites to maternal and neonatal variables of hypoxia. Obstet Gynecol. 1992; 79(3):394-7.
  3. Palmer C, Vannucci RC, Towfighi J. Reduction of perinatal hypoxic-ischaemic brain damage with allopurinol. Pediatr Res. 1990; 27(4):332-6.
  4. Poulsen JP, Rognum TO, Sagustad OD. Changes in oxypurine concentrations in vitreous humor of pigs during hypoxaemia and post-mortem. Pediatr Res. 1990; 28(5):482-4.
  5. Hankins GD, Speer M. Defining the pathogenesis and pathophysiology of neonatal encephalopathy and cerebral palsy. Obstet Gynecol. 2003; 102(3):628-36.
  6. Akcan-Arikan A, Zappitelli M, Loftis LL, Washburn KK, Jefferson LS, Goldstein SL, et al. Modified RIFLE criteria in critically ill children with acute kidney injury. Kidney Int. 2007; 71(10):1028-35.
  7. Bansal SC, Nimbalkar SM. Updated neonatal resuscitation guidelines 2015–major changes. Indian Pediatr. 2016; 53(5):403-8.
  8. Sarnat HB, Sarnat MS. Neonatal encephalopathy following fetal distress: a clinical and electroen-cephalographic study. Arch Neurol. 1976; 33(10):696-705.
  9. Kalckar HM. Differential spectrophotometry of purine compounds by means of specific enzymes. 1. Determination of hydroxypurine compounds. J Biol Chem. 1947; 167(2):429-43.
  10. Knapp ML, Mayne PD. Development of an automated kinetic Jaffe method designed to minimise bilirubin interference in plasma creatinine assays. Clin Chim Acta. 1987; 168(2):239-46.
  11. Basu P, Som S, Choudhuri N, Das H. Correlation between Apgar score and urinary uric acid to creatinine ratio in perinatal asphyxia. Indian J Clin Biochem. 2008; 23(4):361-4.
  12. Bhongir AV, Yakama AV, Saha S, Radia SB, Pabbati J. The urinary uric acid/creatinine ratio is an adjuvant marker for perinatal asphyxia. Eur J Pharm Med Res. 2015; 2(5):520-528.
  13. Nariman S, Mosayebi Z, Sagheb S, Rastad H, Hosseininodeh SS. Urinary uric acid/creatinine ratio as a marker of mortality and unfavorable outcome in NICU-admitted neonates. Iran J Pediatr. 2016; 26(4): e5739.
  14. Vandana V, Amit V, Meena V, Anuradha B, Vivek B, Deepak V, et al. Study of basic biochemical and haematological parameters in perinatal asphyxia and its correlation with hypoxic ischemic encephalopathy (HIE) staging. J Adv Res Biol Sci. 2011; 3(2):79–85.
  15. Bellos I, Fitrou G, Pergialiotis V, Perrea DN, Papantoniou N, Daskalakis GJTJoM-F. Random urine uric acid to creatinine and prediction of perinatal asphyxia: a meta-analysis. J Matern Fetal Neonatal Med. 2019; 32(22):3864–70.
  16. Banupriya C, Doureradjou P, Mondal N, Vishnu B, Koner BC. Can urinary excretion rate of malondialdehyde, uric acid and protein predict the severity and impending death in perinatal asphyxia. Clinical Biochemistry 2008; 41(12):968-73.
  17. Patel KP, MaKadia MG, Patel VI, Nilayangode HN, Nimbalkar SM. Urinary uric acid/creatinine ratio-a marker for perinatal asphyxia. J Clin Diagn Res. 2017; 11(1):SC08-10.
  18. Bader D, Gozal D, Weinger-Abend M, Berger A, Lanir A. Neonatal urinary uric acid/creatinine ratio as an additional marker of perinatal asphyxia. Eur J Pediatr. 1995; 154(9):747-9.
  19. Sreekrishna Y, Eregowda A, Sharma HL. Study of urinary uric acid to creatinine ratio as a biochemical marker of perinatal asphyxia and its correlation with Apgar Score. Int J Contemp Pediatrics. 2018; 5(4):1485.
  20. Choudhary L, Palsania S, Berwal P, Sauparna C, Maheshwari A. Study of urinary uric acid and creatinine ratio as a marker of perinatal asphyxia and its correlation with diferent stages of hypoxic ischemic encephalopathy. J Preg Child Health. 2017; 4:1-4.
  21. Krishnana EPV, Sekar SP, Ponnusamy V. Study of urinary uric acid and creatinine ratio as a marker of neonatal asphyxia for babies born in a tertiary care hospital. Int J Res Med Sci. 2017; 5(12): 5418–23.
  22. American Academy of Pediatrics; Committee on Fetus and Newborn; American College of Obstetricians and Gynecologists; Committee on Obstetric Practice. The APGAR score. Adv Neonatal Care. 2006; 6(4):220-23.