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Johnson RJ, Mandell BF, Schlesinger N, Mount DB, Botson JK, Abdellatif AA, Rhoades R, Singh JA. Controversies and practical management of patients with gout and chronic kidney disease. Kidney Int 2024; 106:573-582. [PMID: 39033815 DOI: 10.1016/j.kint.2024.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/05/2024] [Accepted: 05/28/2024] [Indexed: 07/23/2024]
Abstract
Uric acid is a toxin retained with advancing kidney disease. Clinical manifestations of hyperuricemia include gout and systemic inflammation that are associated with increased risk of cardiovascular mortality. As many as one-third of all patients with chronic kidney disease have a history of gout, yet <25% of these patients are effectively treated to target serum urate levels of ≤6 mg/dl. A major reason for ineffective management of gout and hyperuricemia is the complexity in managing these patients, with some medications contraindicated and others requiring special dosing, potential drug interactions, and other factors. Consequently, many nephrologists do not primarily manage gout despite it being a common complication of chronic kidney disease, leaving management to the primary physician or rheumatologist. We believe that kidney specialists should consider gout as a major complication of chronic kidney disease and actively manage it in their patients. Here, we present insights from nephrologists and rheumatologists for a team approach to gout management that includes the nephrologist.
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Affiliation(s)
- Richard J Johnson
- Division of Renal Diseases, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Brian F Mandell
- Department of Rheumatologic and Immunologic Disease, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland, Ohio, USA
| | - Naomi Schlesinger
- Division of Rheumatology, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - David B Mount
- Renal Divisions, Brigham and Women's Hospital and VA Boston Healthcare System, Harvard Medical School, Boston; Massachusetts, USA
| | - John K Botson
- Orthopedic Physicians Alaska, Anchorage, Alaska, USA
| | | | | | - Jasvinder A Singh
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA.
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Kannuthurai V, Gaffo A. Management of Patients with Gout and Kidney Disease: A Review of Available Therapies and Common Missteps. KIDNEY360 2023; 4:e1332-e1340. [PMID: 37526648 PMCID: PMC10550007 DOI: 10.34067/kid.0000000000000221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 07/13/2023] [Indexed: 08/02/2023]
Abstract
Gout, a common form of inflammatory arthritis, is characterized by deposition of monosodium urate crystals in articular and periarticular tissues. Repeated flares of gout cause joint damage as well as significant health care utilization and decreased quality of life. Patients with CKD have a higher prevalence of gout. Treating Patients with CKD and gout is challenging because of the lack of quality data to guide management in this specific population. This often leads to suboptimal treatment of patients with gout and impaired renal function because concerns regarding the efficacy and safety of available gout therapies in this population often result in significant interphysician variability in treatment regimens and dosages. Acute gout flares are treated with various agents, including nonsteroidal anti-inflammatory drugs, colchicine, glucocorticoids, and-more recently-IL-1 inhibitors. These medications can also be used as prophylaxis if urate-lowering therapy (ULT) is initiated. While these drugs can be used in patients with gout and CKD, there are often factors that complicate treatment, such as the numerous medication interactions involving colchicine and the effect of glucocorticoids on common comorbidities, such as diabetes and hypertension. ULT is recommended to treat recurrent flares, tophaceous deposits, and patients with moderate-to-severe CKD with a serum urate goal of <6 mg/dl recommended to prevent flares. While many misconceptions exist around the risks of using urate-lowering agents in patients with CKD, there is some evidence that these medications can be used safely in Patients with renal impairment. Additional questions exist as to whether gout treatment is indicated for Patients on RRT. Furthermore, there are conflicting data on whether ULT can affect renal function and cardiovascular disease in patients. All of these factors contribute to the unique challenges physicians face when treating patients with gout and CKD.
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Affiliation(s)
- Vijay Kannuthurai
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Angelo Gaffo
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- Birmingham VA Medical Center, Birmingham, Alabama
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3
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Considerations for Choosing First-Line Urate-Lowering Treatment in Older Patients with Comorbid Conditions. Drugs Aging 2022; 39:923-933. [PMID: 36437395 DOI: 10.1007/s40266-022-00986-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2022] [Indexed: 11/29/2022]
Abstract
Gout is the most common inflammatory arthritis in adults. The prevalence of gout increases with age. Urate-lowering treatment (ULT) among older patients is often challenging in that patients frequently suffer insufficient effectiveness or adverse events due to comorbidities, concurrent medications, and altered pharmacokinetics. The large-scale randomized controlled trials (RCTs) directly investigating gout patients regarding cardiovascular (CV) safety have only recently been introduced; CARES and FAST compared the CV safety of the two xanthine oxidase inhibitors (XOis), febuxostat versus allopurinol, in patients with gout. Based on the CARES trial that showed CV concerns with febuxostat, the current international guidelines recommend allopurinol as first-line ULT in gout, while preserving other agents as a second-line treatment, despite a higher potency of febuxostat. XOis would be more suitable than uricosurics to treat older patients with gout due to the high prevalence of chronic kidney disease (CKD) in older patients. However, allopurinol alone might not achieve the target serum uric acid levels below 6 mg/dL and CKD might confer an increased risk of allopurinol induced cutaneous adverse reactions in older patients. Furthermore, as well as the later analysis of CARES participants who were lost to follow-up, data from the FAST trial and real-world studies suggest non-inferior CV safety for febuxostat compared to allopurinol even in the presence of CV diseases. Thus, febuxostat use in older patients with renal impairment may be more positively considered. The combination therapy of a novel uricosuric, verinurad, plus febuxostat reduced albuminuria in hyperuricemic patients with type 2 diabetes and CKD in a phase 2a trial, and further RCTs are awaited. Finally, the sodium-glucose cotransporter-2 inhibitor class of oral hypoglycemic agents, known to exert beneficial CV and renal effects independent of glycemic control, have shown a uricosuric effect and could be used as adjunctive therapy in older patients with cardiorenal comorbidities.
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Zhdan VM, Tkachenko MV, Babanina M. MY, Volchenko GV, Kitura YM, Kyrian OA. GOUT NEPHROPATHY: CHOICE OF INITIAL THERAPY IN A COMORBID PATIENT. BULLETIN OF PROBLEMS BIOLOGY AND MEDICINE 2022. [DOI: 10.29254/2077-4214-2022-3-166-194-205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Goldberg A, Garcia-Arroyo F, Sasai F, Rodriguez-Iturbe B, Sanchez-Lozada LG, Lanaspa MA, Johnson RJ. Mini Review: Reappraisal of Uric Acid in Chronic Kidney Disease. Am J Nephrol 2021; 52:837-844. [PMID: 34673651 DOI: 10.1159/000519491] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 09/06/2021] [Indexed: 12/16/2022]
Abstract
Hyperuricemia predicts the development of chronic kidney disease (CKD) and metabolic complications, but whether it has a causal role has been controversial. This is especially true given the 2 recently conducted randomized controlled trials that failed to show a benefit of lowering uric acid in type 1 diabetes-associated CKD and subjects with stage 3-4 CKD. While these studies suggest that use of urate-lowering drugs in unselected patients is unlikely to slow the progression of CKD, there are subsets of subjects with CKD where reducing uric acid synthesis may be beneficial. This may be the case in patients with gout, hyperuricemia (especially associated with increased production), and urate crystalluria. Here, we discuss the evidence and propose that future clinical trials targeting these specific subgroups should be performed.
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Affiliation(s)
- Avi Goldberg
- Clalit Health Services, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Fumihiko Sasai
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | | | - Miguel A Lanaspa
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Richard J Johnson
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Rocky Mountain VA Medical Center, Aurora, Colorado, USA
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Ong SG, Ding HJ. A single-centre experience of febuxostat as a second-line urate-lowering therapy. MALAYSIAN FAMILY PHYSICIAN : THE OFFICIAL JOURNAL OF THE ACADEMY OF FAMILY PHYSICIANS OF MALAYSIA 2021; 16:50-55. [PMID: 33948142 PMCID: PMC8088732 DOI: 10.51866/oa0892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
INTRODUCTION The purpose of this study was to describe the local experience in terms of drug efficacy and safety using a new xanthine oxidase inhibitor, febuxostat, as a second-line urate-lowering therapy (ULT) in gout patients with normal renal function and chronic kidney disease. METHODS This cross-sectional study included all gout patients who attended the rheumatology clinic from January 2013 to June 2018 and had received febuxostat as a second-line ULT. Analysis focused on the proportion of gout patients who achieved target serum urate (sUA) of <360 μmol/L, duration taken to achieve target sUA, and febuxostat dosage at achievement of target sUA. Safety assessments included comparison of serum creatinine, estimated glomerular filtration rate (eGFR), and serum alanine aminotransferase (ALT) at baseline, at achievement of target sUA, and at 12-monthly intervals. RESULTS Majority (90.9%) of patients achieved target sUA. Median duration required to achieve target sUA was 5.5 months with IQR (interquartile range) of 8.5. Five (22.7%) patients achieved target sUA within one month of therapy with febuxostat 40 mg per day. Eleven (55%) patients achieved target sUA within six months and 16 (80%) by 12 months. Equal proportion of patients achieved target sUA with febuxostat 40 mg per day and 80 mg per day, respectively. There was no significant difference in the changes in serum creatinine level, eGFR and ALT from baseline and at achievement of target sUA, nor at 12-monthly intervals throughout the duration of febuxostat therapy. Apart from three patients who developed hypersensitivity reactions to febuxostat, no other adverse events were reported. CONCLUSION A significant proportion of gout patients with CKD managed to achieve target sUA with a lower dose of febuxostat at 40 mg per day and it is reasonable to maintain this dose for up to six months before considering dose escalation.
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Affiliation(s)
- Swee Gaik Ong
- MD, MRCP, Rheumatology Unit, Department of Medicine, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
| | - Hui Jen Ding
- MBChB, MRCP, Rheumatology Unit, Department of Medicine, Kuala Lumpur Hospital, Jalan Pahang, Kuala Lumpur, Malaysia
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Piani F, Sasai F, Bjornstad P, Borghi C, Yoshimura A, Sanchez-Lozada LG, Roncal-Jimenez C, Garcia GE, Hernando AA, Fuentes GC, Rodriguez-Iturbe B, Lanaspa MA, Johnson RJ. Hyperuricemia and chronic kidney disease: to treat or not to treat. J Bras Nefrol 2021; 43:572-579. [PMID: 33704350 PMCID: PMC8940113 DOI: 10.1590/2175-8239-jbn-2020-u002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 12/28/2020] [Indexed: 12/25/2022] Open
Abstract
Hyperuricemia is common in chronic kidney disease (CKD) and may be present in 50%
of patients presenting for dialysis. Hyperuricemia can be secondary to impaired
glomerular filtration rate (GFR) that occurs in CKD. However, hyperuricemia can
also precede the development of kidney disease and predict incident CKD.
Experimental studies of hyperuricemic models have found that both soluble and
crystalline uric acid can cause significant kidney damage, characterized by
ischemia, tubulointerstitial fibrosis, and inflammation. However, most Mendelian
randomization studies failed to demonstrate a causal relationship between uric
acid and CKD, and clinical trials have had variable results. Here we suggest
potential explanations for the negative clinical and genetic findings, including
the role of crystalline uric acid, intracellular uric acid, and xanthine oxidase
activity in uric acid-mediated kidney injury. We propose future clinical trials
as well as an algorithm for treatment of hyperuricemia in patients with CKD.
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Affiliation(s)
- Federica Piani
- University of Colorado School of Medicine, Division of Renal Diseases and Hypertension, Department of Medicine, Aurora, CO, USA.,University of Bologna, Department of Medical and Surgical Sciences, Bologna, Italy
| | - Fumihiko Sasai
- University of Colorado School of Medicine, Division of Renal Diseases and Hypertension, Department of Medicine, Aurora, CO, USA
| | - Petter Bjornstad
- University of Colorado School of Medicine, Division of Renal Diseases and Hypertension, Department of Medicine, Aurora, CO, USA
| | - Claudio Borghi
- University of Bologna, Department of Medical and Surgical Sciences, Bologna, Italy
| | | | - Laura G Sanchez-Lozada
- University of Colorado School of Medicine, Division of Renal Diseases and Hypertension, Department of Medicine, Aurora, CO, USA
| | - Carlos Roncal-Jimenez
- University of Colorado School of Medicine, Division of Renal Diseases and Hypertension, Department of Medicine, Aurora, CO, USA
| | - Gabriela E Garcia
- University of Colorado School of Medicine, Division of Renal Diseases and Hypertension, Department of Medicine, Aurora, CO, USA
| | - Ana Andres Hernando
- University of Colorado School of Medicine, Division of Renal Diseases and Hypertension, Department of Medicine, Aurora, CO, USA
| | - Gabriel Cara Fuentes
- University of Colorado School of Medicine, Division of Renal Diseases and Hypertension, Department of Medicine, Aurora, CO, USA
| | - Bernardo Rodriguez-Iturbe
- Hospital Universitario de Maracaibo, Instituto de Investigaciones Científicas, Ivic-Zulia, Maracaibo, Venezuela
| | - Miguel A Lanaspa
- University of Colorado School of Medicine, Division of Renal Diseases and Hypertension, Department of Medicine, Aurora, CO, USA
| | - Richard J Johnson
- University of Colorado School of Medicine, Division of Renal Diseases and Hypertension, Department of Medicine, Aurora, CO, USA.,Rocky Mountain VA Medical Center, Aurora, CO, USA
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Farquhar H, Vargas-Santos AB, Pisaniello HL, Fisher M, Hill C, Gaffo AL, Stamp LK. Efficacy and safety of urate-lowering therapy in people with kidney impairment: a GCAN-initiated literature review. Rheumatol Adv Pract 2021; 5:rkaa073. [PMID: 33521512 PMCID: PMC7819867 DOI: 10.1093/rap/rkaa073] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 12/01/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The aim was to evaluate the efficacy, defined as achieving target serum urate <6.0 mg/dl, and safety of urate-lowering therapies (ULTs) for people with gout and chronic kidney disease (CKD) stages 3-5. METHODS PubMed, The Cochrane Library and EMBASE were searched from 1 January 1959 to 31 January 2018 for studies that enrolled people with gout, who had an estimated glomerular filtration rate (eGFR) or creatinine clearance (CrCl) of <60 ml/min and exposure to allopurinol, febuxostat, probenecid, benzbromarone, lesinurad or pegloticase. All study designs other than case reports were included, except for people on dialysis, for whom we did include case reports. RESULTS There were 36 reports with an analysis of efficacy and/or safety based upon renal function: allopurinol (n = 12), febuxostat (n = 10), probenecid (n = 3), benzbromarone (n = 5), lesinurad (n = 5) and pegloticase (n = 1). There were 108 reports that involved people with gout and renal impairment but did not contain any analysis on efficacy and/or safety based upon renal function: allopurinol (n = 84), febuxostat (n = 14), benzbromarone (n = 1), lesinurad (n = 3) and pegloticase (n = 6). Most studies excluded people with more severe degrees of renal impairment (eGFR or CrCl of <30 ml/min). For allopurinol, in particular, there was significant variability in the dose of drug used and the efficacy in terms of urate lowering, across all levels of renal impairment. CONCLUSION There is a lack of evidence regarding the efficacy and/or safety of currently used ULTs according to different levels of renal function. Future studies should include patients with CKD and should report study outcomes stratified by renal function.
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Affiliation(s)
- Hamish Farquhar
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Ana B Vargas-Santos
- Department of Internal Medicine, Rio de Janeiro State University, Rio de Janeiro, Brazil
| | - Huai Leng Pisaniello
- Discipline of Medicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | | | - Catherine Hill
- Discipline of Medicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Angelo L Gaffo
- Division of Rheumatology and Clinical Immunology, University of Alabama, Birmingham
- Birmingham VA Medical Center, Birmingham, AL, USA
| | - Lisa K Stamp
- Department of Medicine, University of Otago, Christchurch, New Zealand
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Kim SH, Lee SY, Kim JM, Son CN. Renal safety and urate-lowering efficacy of febuxostat in gout patients with stage 4-5 chronic kidney disease not yet on dialysis. Korean J Intern Med 2020; 35:998-1003. [PMID: 30959584 PMCID: PMC7373967 DOI: 10.3904/kjim.2018.423] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 03/12/2019] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS The safety and efficacy of febuxostat in patients with stage 4-5 chronic kidney disease (CKD) are still unclear owing to a lack of studies in these patients. Therefore, we aimed to evaluate the effect of febuxostat on renal function, general safety, and efficacy in gout patients with stage 4-5 CKD. METHODS Among 739 patients who had been administered febuxostat from May 2012 to December 2016 at a single hospital in Korea, 370 patients who had been monitored for 1 year were analyzed. Serum uric acid levels and estimated glomerular filtration rate (eGFR) of patients with gouty arthritis were collected at baseline and 1 year after febuxostat administration. RESULTS Among the 370 patients, 280 patients were stage 1-3 CKD, 63 patients were stage 4-5 CKD, and 27 patients were on dialysis. The eGFR of 63 patients with stage 4-5 CKD, excluding dialysis patients, was 19.84 ± 7.08 mL/min/1.73 m2 when they began to take febuxostat and 23.49 ± 16.67 mL/min/1.73 m2 after 12 months (p = 0.13). The urate-lowering effect after 12 months of febuxostat medication showed statistical significance (8.96 ± 2.31 mg/dL at baseline and 4.88 ± 1.68 mg/dL after 12 months, p < 0.01). The difference in incidence of adverse events among patients with stage 1-3 CKD, those with stage 4-5 CKD, and those on dialysis was not significant. CONCLUSION Febuxostat demonstrated renal safety and good urate-lowering efficacy in gout patients with stage 4-5 CKD, who are not yet on dialysis.
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Affiliation(s)
- Sang-Hyon Kim
- Division of Rheumatology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - So-Yeon Lee
- Division of Rheumatology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | | | - Chang-Nam Son
- Correspondence to Chang-Nam Son, M.D. Division of Rheumatology, Department of Internal Medicine, Keimyung University School of Medicine, 56 Dalseong-ro, Jung-gu, Daegu 41931, Korea Tel: +82-53-250-7611 Fax: +82-53-250-7434 E-mail:
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Hu AM, Brown JN. Comparative effect of allopurinol and febuxostat on long-term renal outcomes in patients with hyperuricemia and chronic kidney disease: a systematic review. Clin Rheumatol 2020; 39:3287-3294. [DOI: 10.1007/s10067-020-05079-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/27/2020] [Accepted: 04/01/2020] [Indexed: 12/18/2022]
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Kielstein JT, Heisterkamp M, Jing J, Nadal J, Schmid M, Kronenberg F, Busch M, Sommerer C, Lorenzen JM, Eckardt KU, Köttgen A. Spectrum and dosing of urate-lowering drugs in a large cohort of chronic kidney disease patients and their effect on serum urate levels: a cross-sectional analysis from the German Chronic Kidney Disease study. Clin Kidney J 2019; 14:277-283. [PMID: 33564429 PMCID: PMC7857844 DOI: 10.1093/ckj/sfz136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 09/03/2019] [Indexed: 01/05/2023] Open
Abstract
Background Despite a plethora of studies on the effect of urate-lowering therapy (ULT) in patients with chronic kidney disease (CKD), current guidelines on the treatment of hyperuricaemia and gout vary, especially concerning the need for dose adjustment of allopurinol, whose main metabolite is accumulating with declining renal function. Data on allopurinol dosing and its relationship to renal function, co-medication and sex and the resulting urate level in large cohorts are missing. Methods We studied a subgroup of 2378 patients of the German Chronic Kidney Disease (GCKD) study to determine prescription patterns of ULT among CKD patients under nephrological care and the relationship of ULT dose to urate levels. Prescription and dosing of ULT were manually abstracted from the patient’s paper charts at the baseline visit, in which all currently used medications and their dosing were recorded. Results In this cohort, 39.6% were women, the mean estimated glomerular filtration rate (eGFR) was 51.3 ± 19.3 mL/min/1.73 m2 and the mean age was 59.0 ± 12.4 years. Of the 2378 examined patients, 666 (28.0%) received ULT. The dose of ULT was available for 572 patients. The main ULT agent was allopurinol (94.4%), followed by febuxostat (2.9%) and benzbromarone (2.6%). Of the 540 patients who used allopurinol with a reported daily dose, 480 had an eGFR <60 mL/min/1.73 m2 and 320 had an eGFR <45 mL/min/1.73 m2, 31.5% of the latter (n = 101) received a dose >150 mg/day, the recommended maximal dose for this level of eGFR. The prescribed dose was not related to eGFR: the median eGFR for patients taking 100, 150 and 300 mg/day was 40 [interquartile range (IQR) 32–49], 43 (34–52) and 42 (35–54) mL/min/1.73 m2, respectively. Patients with lower doses of allopurinol had higher serum urate levels than patients with higher (than recommended) allopurinol doses. Sex, alcohol intake, eGFR, use of diuretics and treatment with allopurinol were independent determinants of serum urate levels in multivariate regression analysis. Conclusions The most frequently used drug to lower serum urate levels in this CKD cohort was allopurinol. Even in patients regularly seen by nephrologists, the dose of allopurinol is often not adjusted to the current eGFR. Patients with higher ULT doses achieved better control of their serum urate levels. Lowering of serum urate in CKD patients requires balancing potential adverse effects of allopurinol with suboptimal control of serum urate levels.
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Affiliation(s)
- Jan T Kielstein
- Medical Clinic V: Nephrology
- Rheumatology
- Blood Purification, Academic Teaching Hospital Braunschweig, Braunschweig, Germany.,Department of Nephrology, Hannover Medical School, Hannover, Germany
| | - Markus Heisterkamp
- Medical Clinic V: Nephrology
- Rheumatology
- Blood Purification, Academic Teaching Hospital Braunschweig, Braunschweig, Germany.,Department of Nephrology, Hannover Medical School, Hannover, Germany
| | - Jiaojiao Jing
- Institute of Genetic Epidemiology, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Jennifer Nadal
- Institute for Medical Informatics and Epidemiology, University Hospital Bonn, Bonn, Germany
| | - Matthias Schmid
- Institute for Medical Informatics and Epidemiology, University Hospital Bonn, Bonn, Germany
| | - Florian Kronenberg
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Martin Busch
- Department of Internal Medicine III, University Hospital Jena, Friedrich Schiller University, Jena, Germany
| | - Claudia Sommerer
- Department of Medicine, Division of Nephrology, University Hospital Heidelberg, Heidelberg, Germany
| | - Johan M Lorenzen
- Medical Clinic V: Nephrology
- Rheumatology
- Blood Purification, Academic Teaching Hospital Braunschweig, Braunschweig, Germany.,Department of Nephrology, Hannover Medical School, Hannover, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Department of Nephrology and Hypertension, Friedrich-Alexander Universität Erlangen Nürnberg, Erlangen, Germany
| | - Anna Köttgen
- Institute of Genetic Epidemiology, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
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Hüzmeli C, Timucin M, Güllü M, Hüzmeli C, Öztürk K, Yetimoğlu E, Candan F. Gut Artritli Hastalarda Hiperürisemi ve Kronik Böbrek Hastalığının Prevalansı. ACTA MEDICA ALANYA 2019. [DOI: 10.30565/medalanya.505058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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13
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Jaffe DH, Klein AB, Benis A, Flores NM, Gabay H, Morlock R, Teltsch DY, Chapnick J, Molad Y, Giveon SM, Feldman B, Leventer-Roberts M. Incident gout and chronic Kidney Disease: healthcare utilization and survival. BMC Rheumatol 2019; 3:11. [PMID: 30937425 PMCID: PMC6425669 DOI: 10.1186/s41927-019-0060-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 02/26/2019] [Indexed: 11/16/2022] Open
Abstract
Background Uncontrolled gout can cause significant joint and organ damage and has been associated with impairments in quality of life and high economic cost. Gout has also been associated with other comorbid diseases, such as chronic kidney disease. The current study explored if healthcare resource utilization (HRU) and survival differs between patients with incident gout in the presence or absence of chronic kidney disease (CKD). Methods Clalit Health Services (CHS) data were used to conduct a retrospective population-based cohort study of incident gout between 1/1/2006–31/12/2009. Incident cases of gout were identified and stratified by CKD status and by age group (< 55 and 55+ years). CKD status was defined as a pre-existing diagnosis of chronic kidney disease, chronic renal failure, kidney transplantation, or dialysis at index date. Demographic and clinical characteristics, as well as healthcare resource use, were reported. Results A total of 12,940 incident adult gout patients, with (n = 8286) and without (n = 4654) CKD, were followed for 55,206 person-years. Higher rates of HRU were observed for gout patients with CKD than without. Total annual hospital admissions for patients with gout and CKD were at least 3 times higher for adults < 55 (mean = 0.51 vs 0.13) and approximately 1.5 times higher for adults 55+ (mean = 0.46 vs 0.29) without CKD. Healthcare utilization rates from year 1 to year 5 remained similar for gout patients < 55 years irrespective of CKD status, however varied according to healthcare utilization by CKD status for gout patients 55+ years. The 5-year all-cause mortality was higher among those with CKD compared to those without CKD for both age groups (HR< 55 years = 1.65; 95% CI 1.01–2.71; HR55+ years = 1.50; 95% CI 1.37–1.65). Conclusions The current study suggests important differences exist in patient characteristics and outcomes among patients with gout and CKD. Healthcare utilization differed between sub-populations, age and comorbidities, over the study period and the 5-year mortality risk was higher for gout patients with CKD, regardless of age. Future work should explore factors associated with these outcomes and barriers to gout control in order to enhance patient management among this high-risk subgroup.
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Affiliation(s)
- Dena H Jaffe
- Kantar Health, Ariel Sharon St 4, 52511 Ramat-Gan, Israel
| | - Alyssa B Klein
- 2AstraZeneca, Medical Evidence and Observational Research Centre, 200 Orchard Ridge Drive, Gaithersburg, MD USA
| | - Arriel Benis
- Clalit Research Institute, Zamenhoff 42, Floor - 1, 6435331 Tel Aviv, Israel
| | | | - Hagit Gabay
- Clalit Research Institute, Zamenhoff 42, Floor - 1, 6435331 Tel Aviv, Israel
| | | | | | | | - Yair Molad
- 8Beilinson Hospital, Rabin Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Petach Tikva, Israel
| | - Shmuel M Giveon
- Clalit Research Institute, Zamenhoff 42, Floor - 1, 6435331 Tel Aviv, Israel
| | - Becca Feldman
- Clalit Research Institute, Zamenhoff 42, Floor - 1, 6435331 Tel Aviv, Israel
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Ahn E, Lee S, Lee HN, Lee SG, So MW. Comparison of Efficacy and Safety of Febuxostat in Gout Patients with Chronic Kidney Disease Stage 3 and Stage 4/5. JOURNAL OF RHEUMATIC DISEASES 2019. [DOI: 10.4078/jrd.2019.26.2.118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Eeunyoung Ahn
- Division of Rheumatology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Sunggun Lee
- Division of Rheumatology, Department of Internal Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Han-Na Lee
- Division of Rheumatology, Department of Internal Medicine, Pusan National University Hospital, Busan, Korea
| | - Seung-Geun Lee
- Division of Rheumatology, Department of Internal Medicine, Pusan National University Hospital, Busan, Korea
| | - Min Wook So
- Division of Rheumatology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
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Gunawardhana L, Becker MA, Whelton A, Hunt B, Castillo M, Saag K. Efficacy and safety of febuxostat extended release and immediate release in patients with gout and moderate renal impairment: phase II placebo-controlled study. Arthritis Res Ther 2018; 20:99. [PMID: 29848361 PMCID: PMC5977466 DOI: 10.1186/s13075-018-1593-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 04/16/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Febuxostat immediate release (IR), a xanthine oxidase inhibitor, is indicated for the management of hyperuricemia in patients with gout by lowering urate levels. An extended release (XR) formulation of febuxostat was developed to provide equal or superior efficacy on urate lowering compared with the IR formulation and potentially lower the risk of treatment-initiated gout flares due to an altered pattern of drug exposure. The present study evaluated the efficacy and safety of febuxostat XR and IR formulations in patients with gout and moderate renal impairment (estimated glomerular filtrate rate ≥ 30 and < 60 ml/min). METHODS This was an exploratory, 3-month, phase II, multicenter, placebo-controlled, double-blind proof-of-concept study. Patients (n = 189) were randomized 1:1:1:1:1 to receive placebo or febuxostat IR 40 mg, XR 40 mg, IR 80 mg, or XR 80 mg once daily. Endpoints included: proportion of patients with serum uric acid (sUA) < 5.0 mg/dl at month 3 (primary endpoint), proportion of patients with sUA < 6.0 mg/dl at month 3, and proportion of patients with ≥ 1 gout flare requiring treatment over 3 months. RESULTS At month 3, all febuxostat treatment groups were associated with greater proportions of patients achieving sUA < 5.0 mg/dl (p < 0.05 vs placebo). A greater proportion of patients receiving XR 40 mg achieved sUA < 5.0 mg/dl versus those receiving IR 40 mg (p = 0.034); proportions were similar in the IR 80 mg and XR 80 mg groups. Higher proportions of febuxostat-treated patients achieved sUA < 6.0 mg/dl at month 3 (p < 0.05 vs placebo) and experienced ≥ 1 gout flare (significant for all comparisons, except XR 40 mg). Incidences of treatment-related adverse events were low across all treatment groups; the majority were mild or moderate with no apparent trends correlating with IR or XR doses. The most common treatment-emergent adverse event was hypertension. One death (unrelated to the study drug) was reported. CONCLUSIONS These exploratory data demonstrate that febuxostat (XR and IR) formulations were effective and well tolerated in patients with gout and moderate renal impairment. TRIAL REGISTRATION ClinicalTrials.gov, NCT02128490 Registered on 29 April 2014.
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Affiliation(s)
| | - Michael A Becker
- University of Chicago Pritzker School of Medicine, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA
| | - Andrew Whelton
- Johns Hopkins University, 1737 Beaver Brook Lane, Hunt Valley, MD, 21030, USA
| | - Barbara Hunt
- Takeda Pharmaceuticals, One Takeda Parkway, Deerfield, IL, 60015, USA
| | - Majin Castillo
- Takeda Pharmaceuticals, One Takeda Parkway, Deerfield, IL, 60015, USA
| | - Kenneth Saag
- Birmingham VA Medical Center, 700 S. 19th Street, Birmingham, AL, 35233, USA.,University of Alabama at Birmingham, Faculty Office Tower, Suite 820, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
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Akpabio AA, Dung-gwom PS, Olaosebikan BH, Adelowo OO. Frequency and associations of chronic kidney disease among gout patients from a University Teaching Hospital in Nigeria. Reumatologia 2018; 56:17-23. [PMID: 29686438 PMCID: PMC5911653 DOI: 10.5114/reum.2018.74744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 02/26/2018] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To highlight common precipitants and co-morbidities of gout in Nigerians; determine the frequency of chronic kidney disease (CKD) in Nigerian gout patients, as well as identify significant associations of CKD in gout patients. MATERIAL AND METHODS Retrospective cross-sectional study of gout cases seen at the Rheumatology Clinic of the Lagos State University Teaching Hospital over five years from January 2011 to December 2015. Gout was diagnosed using the 1977 American Rheumatism Association (ARA) criteria. Clinical and laboratory data were extracted and examined for the presence of CKD defined using Kidney Disease Improving Global Outcomes (KDIGO) 2012 guidelines as estimated glomerular filtration rate (eGFR, CKD-EPI) < 60 mls/min/1.73 m2 body surface area for > 3 months. RESULTS One hundred and six gout patients were identified representing 4.5% out of a total of 2330 cases seen during the study period. There were 94 males and 12 females. Oligoarthritis was most frequent (41.5%) with the knee mostly affected (20.1%). Diuretic use was the most frequent precipitant (37.9%) with hypertension the commonest co-morbidity (62.9%). Of 70 patients with complete results, 29 had eGFR (CKD-EPI) < 60 mls/min (41.4%). Age, proteinuria, body mass index (BMI) and packed cell volume (PCV) were significant associations of CKD. Gout patients with CKD were significantly older (61.79 vs. 54.41 years, p = 0.003) with a significantly higher proportion developing proteinuria (15 vs. 4 patients, p ≤ 0.0001) compared to those without CKD. In contrast, those with CKD had a significantly lower BMI (27.31 vs. 29.65 kg/m2, p = 0.026) and PCV (31.97 vs. 37.95%, p = 0.005). CONCLUSIONS Thiazide diuretic use is the most common precipitant while hypertension is the commonest comorbidity in Nigerian gout patients. About two in five Nigerian gout patients had chronic kidney disease at presentation with age, proteinuria, BMI and PCV as significant associations. It is thus imperative to screen for chronic kidney disease when managing gout patients.
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Affiliation(s)
- Akpabio Akanimo Akpabio
- Internal Medicine Department, University of Uyo Teaching Hospital, Uyo, Akwa Ibom State, Nigeria
| | - Pam Stephen Dung-gwom
- Department of Medicine, Jos University Teaching Hospital, Jos, Plateau State, Nigeria
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Juge PA, Truchetet ME, Pillebout E, Ottaviani S, Vigneau C, Loustau C, Cornec D, Pascart T, Snanoudj R, Bailly F, Cornec-Le Gall E, Schaeverbeke T, Saraux A, Dieudé P, Flipo RM, Richette P, Lioté F, Bardin T, Chalès G, Ea HK. Efficacy and safety of febuxostat in 73 gouty patients with stage 4/5 chronic kidney disease: A retrospective study of 10 centers. Joint Bone Spine 2016; 84:595-598. [PMID: 27825577 DOI: 10.1016/j.jbspin.2016.09.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 09/22/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES The allopurinol dose is limited in chronic kidney disease, particularly stage 4/5 chronic kidney disease. Febuxostat has a hepatic metabolism and has been approved without dose adaptation in gouty patients with stage 1-3 chronic kidney disease. We aimed to study the safety and efficacy of febuxostat for stage 4/5 chronic kidney disease. METHODS In this retrospective study, we included patients with (1) a diagnosis of gout, (2) febuxostat treatment, (3) estimated glomerular filtration rate≤30mL/min/1.73m2 (Modification of Diet in Renal Disease formula) at febuxostat initiation and (4) follow-up for at least 3 months after febuxostat initiation. Efficacy, safety and variation in estimated glomerular filtration rate were analyzed. RESULTS We included 73 patients (mean age 70.2±11.8, 61 men, 31 with vascular chronic kidney disease and 18 renal transplantation) with gout (baseline serum uric acid level=9.86±2.85mg/dL, mean gout duration 6.2±7.0 years) from 10 academic centers. Comorbidities included cardiac failure (17.8%), hypertension (98.6%), diabetes mellitus (30.1%), dyslipidemia (64.8%) and history of cardiovascular events (38.4%). At the last visit (mean follow-up 68.5±64.8 weeks), the daily dose of febuxostat was 40mg for 7 patients (10.5%), 80mg for 50 (74.6%) and 120mg for 10 (14.9%). Serum uric acid level was<6mg/dL for 49 patients (67%). Renal function improved for 18 patients, was unchanged for 24 and worsened for 31; 19 patients experienced flares and 1 patient, limb edema. CONCLUSION Febuxostat seemed efficient in gouty patients with stage 4/5 chronic kidney disease. However, safety data were not clear regarding renal function. Larger studies are needed to assess safety.
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Affiliation(s)
- Pierre-Antoine Juge
- Service de rhumatologie, centre Viggo-Petersen, hôpital Lariboisière, Assistance publique-Hôpitaux de Paris, 75010 Paris, France
| | - Marie-Elise Truchetet
- Service de rhumatologie, CHU de Bordeaux, groupe hospitalier Pellegrin, 33000 Bordeaux, France
| | - Evangeline Pillebout
- Service de néphrologie, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris, 75010 Paris, France
| | - Sébastien Ottaviani
- Service de rhumatologie, hôpital Bichat-Claude-Bernard, Assistance publique-Hôpitaux de Paris, 75018 Paris, France
| | - Cécile Vigneau
- Service de néphrologie, hôpital Pontchaillou, 35033 Rennes cedex, France
| | - Clotilde Loustau
- Service de rhumatologie, CHU de Bordeaux, groupe hospitalier Pellegrin, 33000 Bordeaux, France
| | - Divi Cornec
- Service de rhumatologie, hôpital universitaire de Brest, 29200 Brest, France
| | - Tristan Pascart
- Service de rhumatologie, hôpital Saint-Philibert, 59160 Lille, France
| | - Renaud Snanoudj
- Service de néphrologie, hôpital Necker-Enfants-Malades, Assistance publique-Hôpitaux de Paris, 75015 Paris, France
| | - Florian Bailly
- Service de rhumatologie, hôpitaux universitaires Pitié-Salpêtrière-Charles-Foix, Assistance publique-Hôpitaux de Paris, 75013 Paris, France
| | | | - Thierry Schaeverbeke
- Service de rhumatologie, CHU de Bordeaux, groupe hospitalier Pellegrin, 33000 Bordeaux, France
| | - Alain Saraux
- Service de rhumatologie, hôpital universitaire de Brest, 29200 Brest, France
| | - Philippe Dieudé
- Service de rhumatologie, hôpital Bichat-Claude-Bernard, Assistance publique-Hôpitaux de Paris, 75018 Paris, France
| | - René-Marc Flipo
- Service de rhumatologie, CHU Roger-Salengro, 59160 Lille, France
| | - Pascal Richette
- Service de rhumatologie, centre Viggo-Petersen, hôpital Lariboisière, Assistance publique-Hôpitaux de Paris, 75010 Paris, France
| | - Frédéric Lioté
- Service de rhumatologie, centre Viggo-Petersen, hôpital Lariboisière, Assistance publique-Hôpitaux de Paris, 75010 Paris, France
| | - Thomas Bardin
- Service de rhumatologie, centre Viggo-Petersen, hôpital Lariboisière, Assistance publique-Hôpitaux de Paris, 75010 Paris, France
| | - Gérard Chalès
- Service de rhumatologie, CHU de Rennes, 35033 Rennes cedex, France
| | - Hang-Korng Ea
- Service de rhumatologie, centre Viggo-Petersen, hôpital Lariboisière, Assistance publique-Hôpitaux de Paris, 75010 Paris, France; Inserm UMR 1132, université Paris Diderot, Sorbonne Paris Cité, 75475 Paris cedex 10, France.
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Immunopathogenesis and risk factors for allopurinol severe cutaneous adverse reactions. Curr Opin Allergy Clin Immunol 2016; 16:339-45. [DOI: 10.1097/aci.0000000000000286] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Celik G, Yilmaz S, Kebapcilar L, Gundogdu A. Central arterial characteristics of gout patients with chronic kidney diseases. Int J Rheum Dis 2015; 20:628-638. [DOI: 10.1111/1756-185x.12689] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Gulperi Celik
- Division of Nephrology; Department of Internal Medicine; Faculty of Medicine; Selcuk University; Konya Turkey
| | - Sema Yilmaz
- Division of Rheumatology; Department of Internal Medicine; Faculty of Medicine; Selcuk University; Konya Turkey
| | - Levent Kebapcilar
- Division of Endocrinology; Department of Internal Medicine; Faculty of Medicine; Selcuk University; Konya Turkey
| | - Ali Gundogdu
- Department of Internal Medicine; Faculty of Medicine, Selcuk University; Konya Turkey
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Wang W, Bhole VM, Krishnan E. Chronic kidney disease as a risk factor for incident gout among men and women: retrospective cohort study using data from the Framingham Heart Study. BMJ Open 2015; 5:e006843. [PMID: 25869687 PMCID: PMC4401834 DOI: 10.1136/bmjopen-2014-006843] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES Historically, the nature of association between chronic kidney disease (CKD) and gouty arthritis has been unclear. The goal of the present study was to test the hypothesis that CKD is an independent risk factor for developing incident gout. DESIGN Patients were from the original Framingham Heart Study cohort. Using Cox proportional hazard models we estimated the HR of CKD to incident gout among men and women separately after adjusting for age, alcohol consumption, smoking, hypertension, diabetes and body mass index. SETTINGS Patients were all from Framingham, Massachusetts, USA. PARTICIPANTS Excluding patients who had CKD in the first visit from this study, 2159 men and 2558 women were selected covering a 54-year period (1948-2002). RESULTS There were 371 incident cases (231 men and 140 women) of gout over the follow-up of 140,421 person-years. Incidence rates of gout per 1000 person-years for participants with and without CKD were 6.82 (95% CI 5.10 to 9.10) and 2.43 (2.18 to 2.71), respectively. In multivariable Cox models, CKD was associated with gout, with a HR of 1.88 (1.13 to 3.13) among men and 2.31 (1.25 to 4.24) among women. Additional analyses using alternate definitions for CKD and cross-sectional study did not change the results. Sensitivity analysis suggested that the observed findings might be an underestimate of the true relative risk. CONCLUSIONS The present study provides epidemiological evidence to support the notion that CKD is a risk factor for gout.
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Affiliation(s)
- Weiqi Wang
- Stanford University School of Medicine, Palo Alto, California, USA
| | | | - Eswar Krishnan
- Stanford University School of Medicine, Palo Alto, California, USA
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Roughley MJ, Belcher J, Mallen CD, Roddy E. Gout and risk of chronic kidney disease and nephrolithiasis: meta-analysis of observational studies. Arthritis Res Ther 2015; 17:90. [PMID: 25889144 PMCID: PMC4404569 DOI: 10.1186/s13075-015-0610-9] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 03/24/2015] [Indexed: 12/22/2022] Open
Abstract
Introduction To determine the prevalence of chronic kidney disease and nephrolithiasis in people with gout, and the association between gout and prevalent or incident chronic kidney disease and nephrolithiasis. Methods Systematic review and meta-analysis of epidemiological studies. Data sources; MEDLINE, EMBASE and CINAHL databases, hand-searched reference lists, citation history and contact with authors. Eligibility criteria: cohort, case–control or cross-sectional studies which examined the occurrence of chronic kidney disease or nephrolithiasis amongst adults with gout (with or without a non-gout comparator group) in primary care or general population samples. Prevalence and risk estimate meta-analyses were performed using a random-effects model. Results Seventeen studies were included in the meta-analysis (chronic kidney disease n = 7, nephrolithiasis n = 8, both n = 2). Pooled prevalence estimates of chronic kidney disease stage ≥3 and self-reported lifetime nephrolithiasis in people with gout were 24% (95% confidence interval 19% to 28%) and 14% (95% CI 12% to 17%) respectively. Gout was associated with both chronic kidney disease (pooled adjusted odds ratio 2.41, 95% confidence interval 1.86 to 3.11) and self-reported lifetime nephrolithiasis (1.77, 1.43 to 2.19). Conclusions Chronic kidney disease and nephrolithiasis are commonly found amongst patients with gout. Gout is independently associated with both chronic kidney disease and nephrolithiasis. Patients with gout should be actively screened for chronic kidney disease and its consequences.
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Affiliation(s)
- Matthew J Roughley
- School of Medicine, Keele University, Keele, Staffordshire, ST5 5BG, UK.
| | - John Belcher
- School of Computing and Mathematics, Keele University, Keele, Staffordshire, ST5 5BG, UK.
| | - Christian D Mallen
- Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire, ST5 5BG, UK.
| | - Edward Roddy
- Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire, ST5 5BG, UK.
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Jing J, Kielstein JT, Schultheiss UT, Sitter T, Titze SI, Schaeffner ES, McAdams-DeMarco M, Kronenberg F, Eckardt KU, Kottgen A, for the GCKD Study Investigators, Eckardt KU, Titze S, Prokosch HU, Barthlein B, Reis A, Ekici AB, Gefeller O, Hilgers KF, Hubner S, Avendano S, Becker-Grosspitsch D, Hauck N, Seuchter SA, Hausknecht B, Rittmeier M, Weigel A, Beck A, Ganslandt T, Knispel S, Dressel T, Malzer M, Floege J, Eitner F, Schlieper G, Findeisen K, Arweiler E, Ernst S, Unger M, Lipski S, Schaeffner E, Baid-Agrawal S, Petzold K, Schindler R, Kottgen A, Schultheiss U, Meder S, Mitsch E, Reinhard U, Walz G, Haller H, Lorenzen J, Kielstein JT, Otto P, Sommerer C, Follinger C, Zeier M, Wolf G, Busch M, Paul K, Dittrich L, Sitter T, Hilge R, Blank C, Wanner C, Krane V, Schmiedeke D, Toncar S, Cavitt D, Schonowsky K, Borner-Klein A, Kronenberg F, Raschenberger J, Kollerits B, Forer L, Schonherr S, Weissensteiner H, Oefner P, Gronwald W, Zacharias H, Schmid M. Prevalence and correlates of gout in a large cohort of patients with chronic kidney disease: the German Chronic Kidney Disease (GCKD) study. Nephrol Dial Transplant 2014; 30:613-21. [DOI: 10.1093/ndt/gfu352] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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Abstract
Renal involvement and renal function disorders are commonplace in patients with rheumatic diseases and are often decisive for the prognosis. Typical nephrological complications in rheumatology are renal manifestations or delayed sequelae of the underlying disease in addition to drug-induced renal failure, e.g. by nonsteroidal anti-inflammatory drugs (NSAIDs). The differentiation from other common causes of disturbed renal function (e.g. diabetes and hypertension) is important and often difficult in individual cases. Renal involvement can be clinically manifested in many different ways. The spectrum ranges from slight functional disorders with, for example discrete erythrocyturia/proteinuria and normal renal function up to rapidly progressive renal failure. The probability of renal damage also varies greatly between different underlying diseases. For example, renal involvement in rheumatoid arthritis is a rarity but in contrast relatively normal in systemic lupus erythematosus. In the course of the differential diagnostics urine sediment, protein values and sonography are still the most important factors and the indications for kidney biopsy should be generously applied. Early initiation of immunosuppression can substantially improve the renal prognosis of inflammatory systemic diseases.
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Krishnan E. Chronic kidney disease and the risk of incident gout among middle-aged men: a seven-year prospective observational study. ACTA ACUST UNITED AC 2014; 65:3271-8. [PMID: 23982888 DOI: 10.1002/art.38171] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2012] [Accepted: 08/20/2013] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The kidney is the major organ that facilitates excretion of urate in humans. Surprisingly, few studies have assessed whether a reduced glomerular filtration rate (GFR) and/or kidney damage is associated with a higher incidence of gout, and this study was undertaken to address this question. METHODS Data from a 7-year followup of patients enrolled in the Multiple Risk Factor Intervention Trial, a primary prevention trial for cardiovascular disease among 12,866 men ages 35-57 years, were used for the present investigation. Presence of gout was determined by the study physicians from the original trial. Chronic kidney disease was defined using criteria similar to those proposed by the National Kidney Foundation. The Cox proportional hazards regression model was used to assess the association between gout and chronic kidney disease, after accounting for the effects of potential confounders. RESULTS Overall, there were 722 cases of physician- diagnosed incident gout over 76,602 person-years of followup. The standardized incidence ratio of gout among those with chronic kidney disease was 1,217 (95% confidence interval [95% CI] 1,191-1,244). The adjusted hazard ratio (HR) among those with chronic kidney disease was 1.61 (95% CI 1.60-1.61). Each standard deviation decline in the estimated GFR was associated with an HR of 1.43 (95% CI 1.35-1.51). Including the serum urate level, as well as the urate-chronic kidney disease interaction term, as variables in the second analysis did not attenuate the HR. Proteinuria and hematuria, two markers of kidney damage, were associated with an elevated risk of gout independent of the estimated GFR. CONCLUSION Chronic kidney disease manifesting as reduced glomerular function or as presence of blood or protein in the urine increases the risk of incident gout.
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Affiliation(s)
- Eswar Krishnan
- Stanford University School of Medicine, Stanford, California
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Kim SC, Schmidt BMW, Franklin JM, Liu J, Solomon DH, Schneeweiss S. Clinical and health care use characteristics of patients newly starting allopurinol, febuxostat, and colchicine for the treatment of gout. Arthritis Care Res (Hoboken) 2014; 65:2008-14. [PMID: 23861232 DOI: 10.1002/acr.22067] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 06/21/2013] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Gout is a common form of inflammatory arthritis with an increasing prevalence in developed countries. It is well known that many patients with gout have significant comorbidities and high health care utilization. We aimed to describe the clinical characteristics and health care utilization patterns in patients with gout who were newly prescribed allopurinol, febuxostat, or colchicine. METHODS We used US insurance claims data (2009-2011) to conduct a population-based cohort study. RESULTS There were 25,051 allopurinol, 4,288 febuxostat, and 6,238 colchicine initiators. The mean age was 53 years and 83-87% were men. More than one-half of the patients had hypertension and hyperlipidemia, 20% had diabetes mellitus, and 10% had cardiovascular disease. The mean uric acid level was similar across the groups at baseline, ranging from 8.1-8.5 mg/dl. Compared with allopurinol or colchicine initiators, febuxostat initiators had more comorbidities and greater health care utilization, including outpatient, inpatient, or emergency room visits, both at baseline and during followup. Use of gout-related drugs such as opioids, steroids, and nonsteroidal antiinflammatory drugs was most common in febuxostat initiators and least common in colchicine initiators. The median daily doses at both the start and end of treatment were 300 mg for allopurinol, 40 mg for febuxostat, and 1.2 mg for colchicine. The doses of allopurinol and febuxostat were rarely increased during followup. CONCLUSION Patients who started allopurinol, febuxostat, or colchicine for gout generally had hyperuricemia and multiple comorbidities. Febuxostat initiators had more comorbidities and greater use of health care resources and gout-related drugs than the other groups. Overall, the doses of allopurinol or febuxostat remained unchanged over time.
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Yood RA, Ottery FD, Irish W, Wolfson M. Effect of pegloticase on renal function in patients with chronic kidney disease: a post hoc subgroup analysis of 2 randomized, placebo-controlled, phase 3 clinical trials. BMC Res Notes 2014; 7:54. [PMID: 24447425 PMCID: PMC3937145 DOI: 10.1186/1756-0500-7-54] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 01/03/2014] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Pegloticase is approved in the US for treatment of refractory chronic gout. Since chronic kidney disease (CKD) is common in these patients, we conducted a post-hoc analysis of 2 replicate phase 3 trials and the subsequent open-label extension study to determine the effects of pegloticase on renal function in patients with CKD stages 3 and 4, as well as the effects of renal dysfunction on pegloticase efficacy and safety. FINDINGS Patients with renal insufficiency were randomized to pegloticase 8 mg every 2 weeks (n = 42), pegloticase 8 mg every 4 weeks (n = 41), or placebo (n = 20) for 6 months as defined by the study protocols. Renal function was assessed by estimated glomerular filtration rate (eGFR). All patients completing the randomized trials could participate in an open-label extension study for a further 2.5 years. Uric acid response, the primary end point in the trials, was plasma uric acid <6.0 mg/dl for 80% of months 3 and 6.Mean eGFR in both pegloticase dosing cohorts remained constant over the randomized treatment phase and long-term open-label extension study. The number of patients achieving uric acid response was similar across CKD stages (32% stage 1, 23% stage 2, 35% stage 3, and 39% stage 4, respectively, P = 0.3). There was no difference in the pegloticase safety profile based on CKD stage. CONCLUSIONS Pegloticase treatment does not impact eGFR in CKD patients and response to pegloticase is independent of CKD stage. TRIAL REGISTRATION Clinical trial identifier: NCT00325195.
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Affiliation(s)
- Robert A Yood
- Reliant Medical Group, 630 Plantation Street, Worcester, MA 01605, USA
- Reliant Medical Group, 425 North Lake Ave., Worcester, MA 01605, USA
| | - Faith D Ottery
- Savient Pharmaceuticals Inc., 400 Crossing Boulevard, 3rd Floor, Bridgewater, NJ 08807, USA
| | - William Irish
- CTI Clinical Trial and Consulting Services, 8380 Six Forks Road, Suite 203, Raleigh, NC 27615, USA
| | - Marsha Wolfson
- Savient Pharmaceuticals Inc., 400 Crossing Boulevard, 3rd Floor, Bridgewater, NJ 08807, USA
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Becker MA, MacDonald PA, Hunt BJ, Jackson RL. Diabetes and gout: efficacy and safety of febuxostat and allopurinol. Diabetes Obes Metab 2013; 15:1049-55. [PMID: 23683134 PMCID: PMC3902994 DOI: 10.1111/dom.12135] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 04/22/2013] [Accepted: 05/14/2013] [Indexed: 12/22/2022]
Abstract
AIM Assess influences of demographics and co-morbidities of gout patients with or without diabetes on safety and efficacy of urate-lowering agents. METHODS Post-hoc analysis of 312 diabetic and 1957 non-diabetic gout patients [baseline serum urate levels (sUA) ≥8.0 mg/dl] enrolled in a 6-month randomized controlled trial comparing urate-lowering efficacy (ULE) and safety of daily xanthine oxidase inhibitors (XOIs) febuxostat (40 mg or 80 mg) and allopurinol (200 mg or 300 mg). We compared baseline demographic, gout and co-morbid characteristics, ULE, and safety of XOI treatment in diabetic and non-diabetic gout patients. ULE was measured by the proportion of diabetic and non-diabetic patients in each treatment group achieving final visit sUA < 6.0 mg/dl. Safety was monitored throughout the trial. RESULTS Diabetic gout patients were older, more frequently female, and had longer gout duration. Co-morbidities were more frequent among diabetic patients: cardiovascular disease; impaired renal function; hyperlipidemia; and obesity (body mass index >30 kg/m²) (p < 0.001 for all comparisons). Febuxostat 80 mg ULE exceeded that of febuxostat 40 mg or allopurinol (p < 0.050) at all levels of renal function, achieving sUA goal range in the majority of diabetic and non-diabetic patients. Diabetics and non-diabetics reported self-limiting diarrhoea and URIs as the most common adverse events. CONCLUSIONS Despite higher co-morbidity rates in diabetic patients, febuxostat and allopurinol were safe in both groups at the doses tested. Febuxostat 80 mg achieved sUA <6.0 mg/dl more often than febuxostat 40 mg or allopurinol at commonly prescribed doses.
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Affiliation(s)
- M A Becker
- Pritzker School of Medicine, The University of ChicagoChicago, IL, USA
- Correspondence to: Prof. Michael A. Becker, MD, Emeritus of Medicine, The University of Chicago, 237 East Delaware Place, Chicago, IL 60611–1713, USA. E-mail:
| | - P A MacDonald
- Takeda Global Research & Development Center, Inc.Deerfield, IL, USA
| | - B J Hunt
- Takeda Global Research & Development Center, Inc.Deerfield, IL, USA
| | - R L Jackson
- Takeda Global Research & Development Center, Inc.Deerfield, IL, USA
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Thurston MM, Phillips BB, Bourg CA. Safety and efficacy of allopurinol in chronic kidney disease. Ann Pharmacother 2013; 47:1507-16. [PMID: 24259601 DOI: 10.1177/1060028013504740] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To review the evidence surrounding the use of allopurinol in chronic kidney disease (CKD) and discuss safety and efficacy considerations of such use. DATA SOURCES A literature search was conducted through MEDLINE (1950-July 2013), PubMed (1965-July 2013), and International Pharmaceutical Abstracts (1970-July 2013) using the search terms allopurinol and kidney or renal. In addition, reference citations from publications identified were reviewed. STUDY SELECTION AND DATA EXTRACTION All articles in English identified from the data sources were evaluated for inclusion. DATA SYNTHESIS Gout management with allopurinol in patients with CKD can be challenging because of the risk of adverse events and uncertain efficacy. Not all gout treatment guidelines provide recommendations for allopurinol use specifically in patients with CKD. Literature regarding the safety and efficacy of dosing allopurinol in CKD has shown inconsistent results and is based primarily on retrospective, case cohort or observational data. Some trials have demonstrated an increased risk of allopurinol-induced adverse reactions in patients with CKD, whereas others have not confirmed renal insufficiency as a risk factor. More CKD patients achieved a target uric acid level in studies where the allopurinol dose was titrated to effect as compared with those studies in which patients were given renally adjusted or untitrated allopurinol doses. CONCLUSIONS Studies evaluating allopurinol use in patients with CKD have reported inconsistent findings relative to safety and efficacy. Providers should be aware of the potential risk of allopurinol hypersensitivity syndrome as well as the need for reducing the initiation dose and gradual titration of allopurinol to safely achieve a target serum urate level in this population.
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Ramasamy SN, Korb-Wells CS, Kannangara DRW, Smith MWH, Wang N, Roberts DM, Graham GG, Williams KM, Day RO. Allopurinol Hypersensitivity: A Systematic Review of All Published Cases, 1950–2012. Drug Saf 2013; 36:953-80. [DOI: 10.1007/s40264-013-0084-0] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Krishnan E, Akhras KS, Sharma H, Marynchenko M, Wu E, Tawk RH, Liu J, Shi L. Serum urate and incidence of kidney disease among veterans with gout. J Rheumatol 2013; 40:1166-72. [PMID: 23678154 DOI: 10.3899/jrheum.121061] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To study the association between serum urate level (sUA) and the risk of incident kidney disease among US veterans with gouty arthritis. METHODS From 2002 through 2011 adult male patients with gout who were free of kidney disease were identified in the data from the Veterans Administration VISN 16 database and were followed until incidence of kidney disease, death, or the last available observation. Accumulated hazard curves for time to kidney disease were estimated for patients with average sUA levels > 7 mg/dl (high) versus ≤ 7 mg/dl (low) based on Kaplan-Meier analyses; and statistical comparison was conducted using a log-rank test. A Cox proportional hazard model with time-varying covariates was used to estimate the unadjusted and adjusted hazard ratios for kidney disease. RESULTS Eligible patients (n = 2116) were mostly white (53%), with average age 62.6 years, mean body mass index 31.2 kg/m(2), and high baseline prevalence of hypertension (93%), hyperlipidemia (67%), and diabetes (20%). Mean followup time was 6.5 years. The estimated rates of all incident kidney disease in the overall low versus high sUA groups were 2% versus 4% at Year 1, 3% versus 6% at Year 2, and 5% versus 9% at Year 3, respectively (p < 0.0001). After adjustment, high sUA continued to predict a significantly higher risk of kidney disease development (HR 1.43, 95% CI 1.20-1.70). CONCLUSION Male veterans with gout and sUA levels > 7 mg/dl had an increased incidence of kidney disease.
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Affiliation(s)
- Eswar Krishnan
- Stanford University, Stanford, California; Takeda Pharmaceuticals International Inc., Deerfield, Illinois, USA
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Reduced glomerular function and prevalence of gout: NHANES 2009-10. PLoS One 2012; 7:e50046. [PMID: 23209642 PMCID: PMC3507834 DOI: 10.1371/journal.pone.0050046] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Accepted: 10/19/2012] [Indexed: 12/24/2022] Open
Abstract
Background The renal tubule is a major route of clearance of uric acid, a product of purine metabolism. The links between reduced glomerular filtration rate (GFR), hyperuricemia, and gout in the general population are not well understood. The objective of the present study was to estimate prevalence of gout and hyperuricemia among people with impaired GFR in the US general population. Study Design Cross-sectional, survey-weighted analyses of data on adults (age>20 years) in the 2009–10 cycle of the US National Health and Nutrition Examination Surveys (n = 5,589). Associations between self-reported physician diagnosis of gout and degrees of renal impairment were the primary focus of the present analyses. Results In the 2009–2010 period, there was an estimated 7.5 million people with gout in the US. There were 1.25 million men and 0.78 million women with moderate or severe renal impairment and gout. The age standardized prevalence of gout was 2.9% among those with normal GFR compared to 24% among those with GFR<60 ml/min/1.73 m2.In multivariable logistic regression analyses that adjusted for age, gender, body mass index, hypertension, diabetes, hypertension medications, including diuretics, blood lead levels, and hyperlipidemia, the odds ratios of gout and hyperuricemia were 5.9 (2.2, 15.7) and 9.58 (4.3, 22.0) respectively among those with severe renal impairment compared to those with no renal impairment. Approximately 2–3 fold increase in prevalence of gout was observed for each 30 ml/min/1.73 m2 decrease in GFR, after accounting for the above factors. Conclusions Renal glomerular function is an important risk factor for gout. The prevalence of hyperuricemia and gout increases with decreasing glomerular function independent of other factors. This association is non-linear and an eGFR of 60 ml/min/1.73 m2 appears to be a threshold for the dramatic increase in the prevalence of gout.
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Sundy JS. The rheumatology of gout. Adv Chronic Kidney Dis 2012; 19:404-12. [PMID: 23089276 DOI: 10.1053/j.ackd.2012.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 07/24/2012] [Indexed: 11/11/2022]
Abstract
Gout is a metabolic disorder of purine metabolism with primary manifestations of acute and chronic arthritis and tophus formation. The prevalence of gout appears to be increasing and may affect up to 8 million people in the United States. The development of novel therapies for gout after a 40-year hiatus has opened new understanding of this disease. In addition to causing severe musculoskeletal pain, gout is associated with impaired quality of life, reduced functional status, and injury to joints. The quality of care for many patients with gout is unfortunately not in keeping with current guidelines. The approval of new therapies to treat hyperuricemia, such as febuxostat and pegloticase, has increased our knowledge of the challenges of adequately controlling the disease. Rather than providing a comprehensive overview of gout, this review focuses on new developments in the clinical aspects of gout and highlights advances in the drug therapy of gout.
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