October 13, 2019
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Practitioners review steps to reduce the risk of gout in patients with CKD

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H. Joseph Salameh

SAN DIEGO — Once the parade of sharp crystals formed by uric acid start their march through the blood stream and emit their prickly pain to the body’s joints, H. Joseph Salameh, MD, FASN, FACP, told attendees here there are few options available to shutting down the effect short term.

Although treatments like steroids can be administered to patients with chronic kidney disease to begin diminishing the impact of gout — marked by the high concentration of uric acid in the blood — there are steps practitioners can take beyond drug therapy to reduce the risk of flare-ups.

“As humans, we don’t metabolize uric acid. Animals do; we don’t,” Salameh, a Utah nephrologist said. “Two-thirds of it is removed by the kidney, one-third by the gut; but if you have CKD, you are not typically filtering your blood. If you have uric acid, it’s not getting removed,” which creates a higher risk of gout.

Gout occurs when three elements are in place, Salameh said. These include the occurrence of hyperuricemia (typically defined as serum urate concentration of greater than 6.8 mg/dl), monosodium urate crystal formation and deposition in the tissues, and acute and inflammatory responses to the presence of those crystals.

Uric acid is produced in the body during the breakdown of purines, which are chemical compounds found in high amounts in certain foods, such as meat, poultry and seafood. The urate crystals accumulate in joints, causing inflammation and intense pain.

“My patients tell me it is painful ... debilitatingly painful. Usually the pain peaks between 12 and 24 hours, but it can last a few days to a few weeks.”

Aside from swelling, the joints are usually marked by redness and warmth. Onset of the attack seems to occur more often at night and tends to impact the lower extremities, Salameh said. The condition can be hereditary and lead to nephropathy. Some genetic disorders, obesity and certain cancers can be risk factors, along with advanced age and ethnicity. Patients on diuretics and other medications also have a high risk for gout.

Preventive steps require educating patients about the risk of consuming foods and drinks that create a high risk of uric acid, Salameh said. Steps also include limiting the consumption of alcohol, red meat, shellfish, soda and other foods high in acid. Weight loss can also help reduce the risk of gout.

Studies have confirmed that patients who have had gastric bypass surgery and other such procedures to lose weight have also seen a reduced incidence of gout, he said.

While allopurinol is a common drug therapy used to reduce uric acid, the intake of vitamin C (up to 500 milligrams/day) is a preventive step, as well as consuming cherries and coffee (up to 4 cups a day), Salameh said. Although some natural remedies have been explored by patients and clinicians, including products with names like bilberry, Devil’s claw, Pennyroyal and slippery elm, “Their efficacy has not been proven scientifically, so I can’t recommend them; but historically, these remedies have been shown to reduce uric acid," Salameh said. – by Mark E. Neumann

References:

Salameh HJ. Session 114. Presented at: American Nephrology Nurses Association’s Nephrology Nursing Practice, Management and Leadership Conference; Oct. 12-14, 2019; San Diego.

www.annanurse.org

Disclosure: Salameh reports no relevant financial disclosures.