Gout and Chronic Kidney Disease

Gout is a fairly common condition that many of my patients ask about. I have therefore compiled a list of questions and answers to increase your understanding of the condition and treatment.

First of all, what is gout? It’s the most common cause of inflammatory joint disease and numbers of affected people are steadily rising worldwide. Gout is a form of arthritis that causes pain and swelling in one or more joints. Incidence of gout in the United States has more than doubled since the 1960’s. About 4% of adults in the USA develop gout. Gout is caused by elevated elevated uric acid levels in the blood. Uric acid is a byproduct of the breakdown of some foods in the blood, sometimes leading to the formation of sharp like crystals in the joints causing pain and swelling and sometimes joint deformity.

What are the risk factors of gout? High blood pressure is the most common followed by obesity and chronic kidney disease. Other risk factors include injury, fasting, alcohol, heavy diet of red meats, seafood or beverages containing high fructose corn syrup. Advanced age of > 65 is a risk factor. Gout occurs more often in men starting at the age of 30 to 45 years and at age 55 or more in women. Certain medications can cause gout such as thiazide diuretics (hydrochlorothiazide, metolazone), loop diuretics (furosemide, bumetanide, torsemide) cyclosporine, tacrolimus, niacin, atenolol (beta blockers), levodopa, xylitol, niacin.

Are there any complications of gout? People with gout are at increased risk of uric acid kidney stones. Crystals collect in the urinary tract and may form a stone. Kidney stones can create a blockage in the urinary tract and cause kidney damage. Kidney stones occur in about a 15% of the people with gout.

What are the symptoms of Gout? Symptoms of gout can occur suddenly and may include pain, swelling or redness in a joint. Symptoms occur most often in the great toe, but can also affect other joints such as the knee or ankle. The joint may turn red and puffy. In most cases only one joint is affected and symptoms occur most often at night. The pain is usually most severe in the beginning of the attack and last a few days or weeks. Some people with high uric acid levels never have symptoms. After the first attack, a second attack usually occurs within two years.

When uric acid levels remain high for many years with repeated gout attacks it can lead to a condition called tophaceous gout. This is when there is an accumulation of large numbers of urate crystals forming a mass on the joint called tophi. Tophi may cause joint and bone erosion and joint deformity (gouty arthropathy).

How is gout diagnosed? Gout is diagnosed through:

- Listening to the patient’s description of symptoms, when they start, how long they last and when they occur.
- A physical exam, looking for redness and swelling of the joint/s and nodules and joint tenderness.
- A simple blood test screening for elevated uric acid level.
- Needle aspiration of joint fluid looking for uric acid crystals.

What is the treatment for acute gout? Well, you may have heard that NSAIDS relieve symptoms of Gout. Acute gout flares are sometimes treated with NSAIDS (non-steroidal anti inflammatory agents) ibuprofen, Motrin, Advil, Aleve or naproxen. NSAIDS are not recommend for people with chronic kidney or liver disease. Do not use NSAIDS if you have chronic kidney disease, liver disease or stomach ulcers. NSAIDS reduce kidney function and increase risk of bleeding if you have liver disease or have a history of stomach ulcers. Steroids such as prednisone is a treatment that works well and safe for people with kidney disease, however, use with caution with diabetes as it increases blood sugar levels). Colchicine can also be used with kidney disease and has a potential side effect of diarrhea (reduced dosing required with kidney disease).

How can I prevent gout flares? Prevention of gout flares is really the best form of treatment. This may involve life style changes. Please see below.

- Lose weight if you are overweight. Target BMI to < 25.
- Avoid alcohol: beer, wine and hard liquor.
- Avoid food and drinks that contain high fructose corn syrup often found in sodas, store bought cakes and cookies. A non- sugar sweetener called xylitol found in some sugar free/diet foods and drinks may also cause gout flares.
- Follow a low purine diet. Avoid red meats and seafood. Ask your doctor for a complete list of foods.
- Coffee may reduce blood uric acid levels and vitamin C.

Preventative Medications:

- The most commonly used preventative medications are allopurinol (Zyloprim) or febuxostat (Ulorik). These medications lower urate levels in the blood and can significantly reduce the number of repeated gout flares. They are taken daily and require reduced dosing with kidney disease. Target uric acid level is < 6mg/dL.

Learn more about gout and treatment from your health care provider. Remember, all recommendations are not meant for everyone and should be individualized to each person. Ask your doctor /health care provider what is best for you.

by Jeanne Krawiec ANP-BC