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Elevated serum urate (SU) concentration is the central risk factor for the development of gout. The aim of this study was to examine the incidence of gout in people with low and normal SU levels (< 7.00 mg/dL).    Methods  Longitudinal cohort data from the Atherosclerosis Risk in Communities Study (ARIC), Coronary Artery Risk Development in Young Adults Study (CARDIA), and both the Original and Offspring cohorts of the Framingham Heart Study (FHS) were used to determine incident gout by baseline SU over 3, 5, 10, 12 and 15 year periods. A Cox proportional hazards model with covariables of age, gender, ethnicity, and cohort was calculated to report the hazard ratios (HR) for incident gout.    Results  The incidence of gout at 15 years for a baseline SU < 4.00 mg/dL was 0.59%, 4.00–4.49 mg/dL was 1.28%, 4.50–4.99 mg/dL was 0.86%, 5.00–5.49 mg/dL was 0.94%, 5.50–5.99 mg/dL was 1.52%, 6.00–6.49 mg/dL was 2.91%, 6.50–6.99 mg/dL was 3.2%, and > 7.00 mg/dL was 12.2%. In an adjusted Cox proportional hazards model, compared to the referent baseline SU < 4.00 mg/dL, there was a non-significant increase in incident gout for baseline SU bands between 4.00–5.49 mg/dL, whereas incident gout was significantly increased for SU 5.50–5.99 mg/dL (HR 2.60), 6.00–6.49 mg/dL (HR 3.70), 6.50–6.99 mg/dL (HR 5.24) and > 7.00 mg/dL (HR 18.62).    Conclusion  A baseline SU of 5.50 mg/dL or more is a risk factor for development of gout over 15 years. However, incident gout does occur over time in a small proportion of people with lower baseline SU levels.    Supplementary Information  The online version contains supplementary material available at 10.1186/s41927-021-00204-4.

Longitudinal development of incident gout from low-normal baseline serum urate concentrations: individual participant data analysis