Gout Management in Patients With CKD: A Review

The management of gout in patients with chronic kidney disease (CKD) can be challenging due to multiple factors. These include limitations on the type or doses of medications used. Although limitations or exclusions of some treatment options are warranted, others that are traditionally followed, such as the doses used for urate-lowering therapies such as 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 CKD 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 CKD, such as the "start-low-go-low" approach, are reviewed as well as considerations for kidney transplant recipients. Although there is a potential role of sodium/glucose cotransporter 2 inhibitors in lowering serum urate, it is limited in CKD. Finally, the use of immunomodulators to improve outcomes for pegloticase, a pegylated form of uricase, shows promise for increasing the utility of pegloticase in cases where it is warranted.