Management of gout in chronic kidney disease: a G-CAN Consensus Statement on the research priorities

Abstract

Gout and chronic kidney disease (CKD) frequently coexist, but quality evidence to guide gout management in people with CKD is lacking. Use of urate-lowering therapy (ULT) in the context of advanced CKD varies greatly, and professional bodies have issued conflicting recommendations regarding the treatment of gout in people with concomitant CKD. As a result, confusion exists among medical professionals about the appropriate management of people with gout and CKD. This Consensus Statement from the Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN) discusses the evidence and/or lack thereof for the management of gout in people with CKD and identifies key areas for research to address the challenges faced in the management of gout and CKD. These discussions, which address areas for research both in general as well as related to specific medications used to treat gout flares or as ULT, are supported by separately published G-CAN systematic literature reviews. This Consensus Statement is not intended as a guideline for the management of gout in CKD; rather, it analyses the available literature on the safety and efficacy of drugs used in gout management to identify important gaps in knowledge and associated areas for research.

Fig. 1. Stages of gout.

Gout progresses through several classic disease stages and corresponding clinical manifestations. In some cases, advanced disease stages and complications can appear prematurely, without earlier disease stages or clinical manifestations being apparent (for example, tophaceous gout without prior gout flares), although this pattern is uncommon. MSU, monosodium urate. Adapted from ref., Springer Nature Limited.

Fig. 2. Reasons for poor outcomes in people with CKD and gout.

This schematic provides a conceptual framework to explain poor management and outcomes in people with gout and chronic kidney disease (CKD). No good-quality evidence is available to guide treatment decisions because clinical trials have traditionally excluded participants with advanced CKD or, when these participants are enrolled, the trials have failed to report outcomes stratified by renal function. In addition, comparing and contrasting studies is difficult because of variability in reporting of outcomes for both urate-lowering therapy (ULT) and gout flare studies (this problem is not unique to gout in the context of CKD). In addition, many health-care team members involved in the management of people with gout and CKD have valid concerns about confusing guidance (conflicting recommendations among treatment guidelines from prominent societies), and harbour misconceptions (including that ULTs will have an adverse effect on renal function (and the ULT dose should therefore be adjusted), the risk of adverse effects (mainly allopurinol hypersensitivity) and that ULT will have reduced efficacy). These factors lead to excessively conservative approaches to the treatment of gout in people with CKD, which often does not achieve optimal treatment outcomes.