Managing Hyperuricemia and Gout in Chronic Kidney Disease

A Clinical Conundrum

Kulanka H. Premachandra; Richard O. Day; Darren M. Roberts


Curr Opin Nephrol Hypertens. 2021;30(2):245-251. 

In This Article

Abstract and Introduction


Purpose of Review: There is controversy regarding the impact of hyperuricemia on the progression of chronic kidney disease (CKD), and gout remains sub optimally managed in this population. We discuss the prescribing of drugs for the treatment of gout in patients with CKD.

Recent Findings: There is a lack of consensus from expert guidelines, and prescribers have concerns regarding the risk of adverse reactions from medicines used to treat gout. These situations appear to contribute to suboptimal management of gout in this cohort. Recent data have challenged the role of urate lowering therapy (ULT) in the management of asymptomatic hyperuricemia in CKD.

Summary: ULT should be commenced in all patients with severe, recurrent disease, tophaceous gout and evidence of joint damage. Most international guidelines recommend a treat-to-target approach for the management of gout. In CKD, ULT should be started at low dose with up titration adjusted to serum urate levels, rather than being based on the creatinine clearance. If patients fail first-line therapy, alternative agents are utilized, the specific agent depending on ease of access, burden of disease and other comorbidities. This approach should be incorporated into routine practice to ensure optimal treatment of gout in CKD. More research is required to investigate whether treatment of asymptomatic hyperuricemia has clinical benefits.


Gout occurs as a consequence of prolonged hyperuricemia resulting in monosodium urate crystal deposition in joints, bone and soft tissues.[1,2] It is the most common inflammatory arthritis in men. The natural history progresses from asymptomatic hyperuricemia, acute flares and finally to chronic arthritis and/or tophaceous disease.[3]

Gout is an important condition. Epidemiological studies from many countries note that gout has a prevalence ranging from 0.1 to 10%, and an incidence from 0.3 to 6 cases per 1000 person-years,[3] and both are increasing.[4]

Gout is also associated with increased disability-adjusted life years, increased use of healthcare resources and absence from work.[5–7] It is also frequently associated with comorbidities such as diabetes mellitus, obesity, chronic kidney disease (CKD), dyslipidemia, hypertension, cardiovascular disease, hypothyroidism, depression, chronic pulmonary disease and osteoarthritis.[8]

Despite the above findings and the existence of effective treatment options, gout continues to be undiagnosed, misdiagnosed and suboptimally managed.[9–11]