Study Investigates Urate-Lowering Therapy for Gout Patients on Hemodialysis

Gout is a common form of inflammatory arthritis, affecting an estimated 3.9% of US adults. It is associated with high serum uric acid (UA) in the blood forming monosodium urate (MSU) crystals. These crystals deposit in and around the joints, causing flares of swelling, pain, and redness in joints.

In addition to several other comorbidities, gout has been linked to the development of chronic kidney disease (CKD) and end-stage renal disease (ESRD). Hemodialysis (HD) is a ERSD treatment that filters waste and water from the blood, fulfilling the role of healthy kidneys. According to the 2020 American College of Rheumatology Guideline for the Management of Gout, pharmacologic urate-lowering therapy (ULT) is recommended for patients with CKD stages 2-5, or ESRD with prior gout attacks and current hyperuricemia.

Prior studies have shown that patients with ESRD undergoing HD have reduced incidences of gout flares while in treatment. Researchers at the MetroHealth Medical Center investigated the characteristics of UA levels in patients with ESRD on HD and evaluated whether patients on HD should continue to receive ULT.

The observational, retrospective cohort study was published in the International Journal of Rheumatic Diseases. Researchers extracted data from the medical records of patients diagnosed with both gout and ESRD on HD. The main outcome measurements included UA levels and the use of ULTs before and after HD initiation.

A total of  21 patients had MSU crystal-proven gout diagnosis with a mean age of 65 years. Ten of these patients had data on UA levels before and after HD. The mean US level before HD was 8.4 mg/dL, which is more than 2.0 mg/dL greater than the target serum uric acid level of <6.0 mg/dL. Prior to beginning HD, 19 patients were receiving allopurinol, one patient received febuxostat, and one received pegloticase.

After HD, the mean UA level decreased to 3.98 mg/dL. Within one year of starting HD, seven patients receiving discontinued ULT, and two patients discontinued ULT within 10 years. Both patients receiving febuxostat and pegloticase discontinued ULT after initiating HD.

“We found poor monitoring of gout in our study patients, specifically a lack of serum UA monitoring after initiation of HD and continuation of the same dose of allopurinol contrary to recommended dosage post-HD,” researchers noted.

They went on to write that, “Improved collaboration between primary care providers, rheumatologists, and nephrologists can help to ensure proper monitoring of these patients and to weigh the risk and benefits of continued ULT based on the serum UA level.”