Management of Acute and Chronic Gout – The Nephrology Perspective

Abstract

Background: Gout and its treatment pose a greater burden on patients with chronic kidney disease (CKD). We review the incidence of hyperuricemia in patients with CKD, mechanism of urate handling by the kidney and management of acute and chronic gout in patients with CKD and on renal replacement therapy.

Renal Handling of Urate: Reabsorption of urate is enhanced by the presence of monocarboxylate anions. URAT 1 is the predominant urate-anion exchanger followed by the GLUT 9 transporter. Various drugs inhibit these transporters. NPT1 and NPT4 are transporters which secrete urate and NPT 4’s action is inhibited by diuretics. Alcohol, volume depletion, salt restriction and high PTH levels cause hyperuricemia.

Management of Gout in CKD: For acute gout attack, NSAIDs are relatively contraindicated. Lower doses of colchicine are recommended in CKD and even lower doses for ESRD patients. Glucocorticoids are the preferred agents in renal patients. In chronic gout, the goal is to maintain uric acid levels < 6 mg/dl. Prophylactic colchicine is recommended for 3 months in patients without tophi and 6 months for patients with tophi. Allopurinol, at doses ranging from 100 to 300 mg/day, lowers serum uric acid levels, but it has not been shown to slow CKD progression. Safety data for Febuxostat is lacking in advance CKD, while Probenecid is in effective in patient with GFR < 30ml/min. Dose reduction for Pegloticase is not necessary.