From the Guidelines
Asymptomatic hyperuricemia in Chronic Kidney Disease (CKD) should not be treated with uric acid–lowering interventions to delay CKD progression. The KDIGO 2024 clinical practice guideline for the evaluation and management of CKD recommends against using agents to lower serum uric acid in people with CKD and asymptomatic hyperuricemia to delay CKD progression (2D) 1. This recommendation is based on the lack of consistent evidence demonstrating that lowering uric acid levels slows CKD progression or improves outcomes in asymptomatic patients.
Key points to consider in the management of hyperuricemia in CKD include:
- The presence of symptoms such as gout, which may necessitate uric acid–lowering intervention 1
- The use of xanthine oxidase inhibitors, such as allopurinol, in preference to uricosuric agents in people with CKD and symptomatic hyperuricemia 1
- Nonpharmacological interventions, such as limiting alcohol, meats, and high-fructose corn syrup intake, which may help prevent gout 1
In general, the risks of medication side effects, drug interactions, and pill burden may outweigh potential benefits in asymptomatic patients, supporting a conservative management approach. However, treatment is clearly indicated if the patient develops gout attacks, tophi, or uric acid kidney stones, regardless of CKD status.
From the FDA Drug Label
Asymptomatic hyperuricemia is not an indication for treatment with allopurinol tablets (see INDICATIONS AND USAGE) The FDA drug label does not support the treatment of asymptomatic hyperuricemia in CKD.
- Key points:
- Asymptomatic hyperuricemia is not an indication for allopurinol treatment.
- Allopurinol is used for the management of patients with signs and symptoms of primary or secondary gout.
- The use of allopurinol should be individualized for each patient and requires an understanding of its mode of action and pharmacokinetics. 2
From the Research
Treatment of Asymptomatic Hyperuricemia in CKD
- The treatment of asymptomatic hyperuricemia in patients with Chronic Kidney Disease (CKD) is a topic of controversy, with some studies suggesting that it may be beneficial to lower serum uric acid levels, while others argue that it may not be necessary 3, 4.
- Some studies have shown that urate-lowering therapy may help to prevent and delay the decline of renal function in patients with CKD, particularly those with high renal risk and/or declining renal function 5, 6.
- However, other studies have found that the evidence for treating asymptomatic hyperuricemia in CKD patients is limited, and that more research is needed to determine the benefits and risks of treatment 3, 7.
- A survey of Korean physicians found that the majority of respondents treated asymptomatic hyperuricemia in CKD patients to prevent CKD progression and cerebro-cardiovascular complications, with febuxostat being the preferred medication 6.
- The weight of the evidence suggests that asymptomatic hyperuricemia is likely injurious, particularly in subgroups with systemic crystal deposits, frequent urinary crystalluria or kidney stones, and high intracellular uric acid levels, and that carefully designed clinical trials are needed to test the benefits of lowering uric acid in these patients 7.
Factors to Consider in Treatment
- Serum uric acid levels: treatment may be considered for patients with high serum uric acid levels, particularly those with levels above 8.0 or 9.0 mg/dL 6.
- Renal function: treatment may be considered for patients with declining renal function or high renal risk 5, 6.
- Presence of urate crystals in urine sediment and/or signs of asymptomatic articular damage by urates: these may be used as guides for treatment 4.
- Trends in creatinine, proteinuria, and serum urate levels: these may be used to monitor the effectiveness of treatment and guide decision-making 4.