Rethinking Gout in Chronic Kidney Disease

Gout and chronic kidney disease (CKD) are intrinsically linked, creating a cycle of metabolic dysfunction that presents distinct diagnostic and treatment challenges. In episode 2 of the Managing Uncontrolled Gout series, nephrologists Jessica Coleman, MD, Nissreen Elfadawy, MD, MS, and Abdul Abdellatif, MD, examine the nuanced relationship between these conditions and stress the importance of early recognition, individualized therapy, and multidisciplinary coordination.

Coleman, based in South Carolina, emphasizes that uric acid elimination is primarily renal, and impaired kidney function leads to systemic urate accumulation. In patients with CKD, this process is often silent until flares occur, and delayed recognition can result in progressive joint damage and worsening renal function. Given the overlap with comorbidities like hypertension and diabetes, gout in CKD is frequently underdiagnosed. She recommends active screening and patient engagement to identify gout earlier and adjust treatment as renal function evolves. Oral urate-lowering therapies may be less effective or contraindicated in CKD, requiring personalized dosing and consideration of alternative options.

Elfadawy expands on the bidirectional nature of the relationship: gout not only results from CKD, but also contributes to its progression. She warns that NSAIDs and even some antihypertensives can exacerbate renal dysfunction in patients with gout, highlighting the need for a nuanced pharmacologic approach. She advocates for a treat-to-target strategy, with uric acid levels maintained below 6 mg/dL, and points to the promise of newer agents such as uricase therapies and infusible biologics for refractory cases.

Abdellatif, of Baylor College of Medicine, underscores the importance of cross-specialty coordination. Patients with gout may first present to rheumatologists or podiatrists, but nephrologists are essential for long-term disease management, especially given the renal pathophysiology at the core of most cases. He notes a strong familial pattern in some patient populations and encourages clinicians to consider genetic contributions and proactively screen at-risk individuals.

Together, these nephrology experts emphasize the need for collaborative, individualized care that addresses gout and CKD as interconnected systemic diseases—not isolated pathologies.