Serum urate levels and therapy in adults treated with long‐term dialysis: a retrospective cross‐sectional study

Abstract

Background The management of gout in chronic kidney disease and end‐stage renal disease is challenging and remains controversial. There are limited data on the use of urate‐lowering therapy in people receiving dialysis. Aim To estimate the point prevalence of gout, gout treatment and achievement of target serum urate (SU) among adults treated with long‐term dialysis. Methods Three secular cohorts of adults receiving dialysis for at least 90 days on 1 February 2017, 1 January 2016 and 1 January 2015 were identified. Medical records were reviewed for SU concentrations. Results were compared between haemodialysis (HD) and peritoneal dialysis (PD), and participants prescribed and not prescribed urate‐lowering therapy. The percentage reduction in SU 24‐ and 48‐h post‐HD was estimated based on data from a previous study. SU concentrations were then used to estimate the percentage time the SU was <0.36 mmol/L using linear interpolation. Results Of 216 dialysis patients, 61 (point prevalence 28.2%, 95% confidence interval 22.35–34.8%) had a diagnosis of gout. The mean (SD) age among those with gout was 61 years (14.4), 46 (75.4%) were men and 18 (31.1%) identified as Māori or Pacific Island. Forty‐two (68.9%) were prescribed allopurinol (mean (SD) dose 116.0 ± 66.9 mg/day). 46% had a predialysis SU ≤0.36 mmol/L on less than 25% of occasions and 23% were below target on 76–100% of occasions. SU was below target 41% of time, with no statistically significant difference in those on HD or PD (P = 0.39), and those prescribed or not prescribed allopurinol (P = 0.55). Conclusions Gout is experienced by approximately one in four adults treated with dialysis and two‐thirds are prescribed allopurinol. A minority have SU at a target sufficient to prevent gout despite allopurinol and HD. A treat to target SU should be considered in those with SU above target.

Urate‐lowering therapy for patients with gout on hemodialysis

“…11 However, another study by Yeo et al evaluated 216 patients on dialysis (HD and peritoneal dialysis), almost 25% of whom experienced gout, suggesting that HD alone is insufficient to achieve target UA mandating ULT and treat-to-target approach in this patient population. 16 Our results suggest that initiation of HD is associated with a decrease in UA levels in ESRD patients. Compared to current guideline recommendations to continue ULT, our results found that over 50% of patients on allopurinol at the start of HD had the medication stopped after they started HD.…”

“…Gout is experienced in almost 20% of patients with CKD stage 3, compared to 5% of those with normal kidney function 16 . In a large analysis of 601 patients from 5 outpatient dialysis centers in Germany, investigators noted that the incidence of gout flares in patients on HD was only 3.6%, and hyperuricemia increased the risk by 17% 11 .…”

“…11,18 Gout is experienced in almost 20% of patients with CKD stage 3, compared to 5% of those with normal kidney function. 16 In a large analysis of 601 patients from 5 outpatient dialysis centers in Germany, investigators noted that the incidence of gout flares in patients on HD was only 3.6%, and hyperuricemia increased the risk by 17%. 11 However, another study by Yeo et al evaluated 216 patients on dialysis (HD and peritoneal dialysis), almost 25% of whom experienced gout, suggesting that HD alone is insufficient to achieve target UA mandating ULT and treat-to-target approach in this patient population.…”

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

“…However, this is not a universal finding 60 . It has also been reported that serum urate is at the target concentration less often in those on haemodialysis than in those on peritoneal dialysis, perhaps due to the intermittent rather than con tinuous removal of urate through dialysis 60 . The data for use of allopurinol and febuxostat in patients undergoing haemodialysis are predominantly limited to case reports and case series [61][62][63][64][65] .…”

“…It has been suggested that haemodialysis should reduce serum urate concentration such that specific ULT is no longer required 58 , 59 . However, this is not a universal finding 60 . It has also been reported that serum urate is at the target concentration less often in those on haemodialysis than in those on peritoneal dialysis, perhaps due to the intermittent rather than continuous removal of urate through dialysis 60 .…”