What is the management approach for patients with hyperuricemia (elevated uric acid levels) and Chronic Kidney Disease (CKD)?

From the Guidelines

Patients with hyperuricemia and Chronic Kidney Disease (CKD) should be offered uric acid-lowering intervention, particularly those with symptomatic hyperuricemia, as recommended by the KDIGO 2024 clinical practice guideline 1. The management approach for these patients involves a combination of lifestyle modifications and pharmacological interventions.

• Lifestyle modifications include limiting alcohol intake, avoiding high-purine foods, and adequate hydration, which can help prevent gout and reduce uric acid levels.
• For pharmacological management, xanthine oxidase inhibitors, such as allopurinol or febuxostat, are preferred over uricosuric agents in people with CKD and symptomatic hyperuricemia 1.
• The FDA-approved dosing for colchicine is 1.2 mg followed by 0.6 mg an hour later for acute flares, and low-dose colchicine or intra-articular/oral glucocorticoids are preferable to nonsteroidal anti-inflammatory drugs (NSAIDs) for symptomatic treatment of acute gout in CKD 1.
• It is essential to monitor kidney function, uric acid levels, and medication side effects regularly, as treating hyperuricemia may potentially slow CKD progression by reducing urate crystal deposition in the kidneys and decreasing oxidative stress and inflammation that can damage kidney tissue.
• The most recent guideline recommends not using agents to lower serum uric acid in people with CKD and asymptomatic hyperuricemia to delay CKD progression 1. Key considerations in the management of hyperuricemia in CKD patients include:
• Initiating uric acid-lowering therapy after the first episode of gout, particularly if there is no avoidable precipitant or serum uric acid concentration is >9 mg/dl [535 μmol/l] 1.
• Prescribing xanthine oxidase inhibitors, such as allopurinol or febuxostat, as the preferred pharmacological treatment for symptomatic hyperuricemia in CKD patients 1.

From the FDA Drug Label

Allopurinol tablets can substantially reduce serum and urinary uric acid levels in previously refractory patients even in the presence of renal damage serious enough to render uricosuric drugs virtually ineffective The management approach for patients with hyperuricemia and Chronic Kidney Disease (CKD) involves the use of allopurinol to reduce serum and urinary uric acid levels.

• Key points:
  • Allopurinol inhibits the formation of uric acid, reducing both serum and urinary uric acid levels.
  • It can be effective in patients with renal damage, where uricosuric drugs may be ineffective.
  • The use of allopurinol requires individualization for each patient, considering its mode of action and pharmacokinetics 2.
  • It is indicated for the management of patients with signs and symptoms of primary or secondary gout, as well as those with leukemia, lymphoma, and malignancies who are receiving cancer therapy that causes elevations of serum and urinary uric acid levels 2.
  • Important consideration: Treatment with allopurinol should be carefully assessed and monitored to determine its benefits and risks in each patient.

From the Research

Management Approach for Hyperuricemia and CKD

The management of patients with hyperuricemia and Chronic Kidney Disease (CKD) involves a combination of lifestyle interventions and pharmacological treatments.

• Lifestyle interventions such as exercise, weight reduction, low consumption of purine-rich meat, and avoiding high fructose intake are recommended for all hyperuricemic patients 3.
• Lowering urate drugs such as allopurinol or febuxostat may be an option as a renoprotective agent, although randomized clinical trials evaluating the safety and efficacy of these drugs are limited 3.
• A survey of Korean physicians found that the majority (80.4%) reported treating asymptomatic hyperuricemia in CKD patients, with the most important reasons being renal function preservation and cerebro-cardiac protection 4.
• The treatment of hyperuricemia with allopurinol has been shown to lower blood pressure and inhibit the progression of renal damage in CKD patients, although the cessation of treatment can lead to a rise in blood pressure and renal damage 5.

Pharmacological Treatments

• Xanthine oxidase inhibitors, uricosuric medications, and recombinant uricases are available treatment options for hyperuricemia 6.
• The results of recent trials and meta-analysis seem to support the therapeutic strategy of treating asymptomatic hyperuricemia, although the target level of uric acid remains debated 6.
• Medications with cardio and nephroprotective properties, such as those that reduce serum uric acid levels, may be used in patients with hyperuricemia and other cardiovascular complications 6.

Lifestyle Recommendations

• Weight reduction with daily exercise and limiting intake of red meat and sugary beverages can help reduce uric acid levels and the risk of gout and comorbidities 7.
• Dairy products, vegetables, nuts, legumes, fruits (less sugary ones), and whole grains are healthy choices for the comorbidities of gout and may also help prevent gout by reducing insulin resistance 7.
• Coffee and vitamin C supplementation could be considered as preventive measures as these can lower urate levels, as well as the risk of gout and some of its comorbidities 7.