Gout Management in Patients With CKD.

Abstract

The management of gout in patients with chronic kidney disease can be challenging due to multiple factors. These include limitations on the type or doses of medications used. While limitations or exclusions of some treatment options are warranted, others that are traditionally followed, such as the doses used for urate lowering therapies like allopurinol or febuxostat, may lead to undertreatment of gout. In this review, guidelines from consensus groups are discussed with a focus on management of gout in patients with chronic kidney disease and appropriate dose adjustments beyond traditional kidney-dosed limits. Studies in the literature with regard to risk factors for allopurinol hypersensitivity syndrome are reviewed, including HLAB*5801 allele testing. Additionally, current evidence that allows providers to optimize both the effectiveness and safety of gout management in the setting of chronic kidney disease, such as the "start-low-go-low" approach are reviewed, as well as considerations for kidney transplant recipients. While there is a potential role of sodium/glucose cotransporter 2 inhibitors in lowering serum urate, it is limited in chronic kidney disease. Lastly, the use of immunomodulators to improve outcomes for pegloticase, a pegylated form of uricase, show promise for increasing the utility of pegloticase in cases where it is warranted.