Abdellatif Abdul A, Elkhalili Naser
1Division of Nephrology, Kidney Hypertension Transplant Clinic, Clear Lake Specialties, Baylor College of Medicine, Webster, TX; and 2Clear Lake Arthritis Clinic and University of Texas Medical Branch, Webster, TX.
Am J Ther. 2014 Nov-Dec;21(6):523-34. doi: 10.1097/MJT.0b013e318250f83d.
Chronic kidney disease (CKD) is a comorbid condition that affects, based on recent estimates, between 47% and 54% of patients with gouty arthritis. However, data from randomized controlled trials in patients with gouty arthritis and CKD are limited, and current gouty arthritis treatment guidelines do not address the challenges associated with managing this patient population. Nonsteroidal anti-inflammatory drugs and colchicine are recommended first-line treatments for acute gouty arthritis attacks. However, in patients with CKD, nonsteroidal anti-inflammatory drugs are not recommended because their use can exacerbate or cause acute kidney injury. Also, colchicine toxicity is increased in patients with CKD, and dosage reduction is required based on level of kidney function. Allopurinol, febuxostat, and pegloticase are all effective treatments for controlling elevated uric acid levels after the treatment of an acute attack. However, in patients with CKD, required allopurinol dosage reductions may limit efficacy; pegloticase requires further investigation in this population, and febuxostat has not been studied in patients with creatinine clearance<30 mL/min. This article reviews the risks and benefits associated with currently available pharmacologic agents for the management of acute and chronic gouty arthritis including urate-lowering therapy in patients with CKD. Challenges specific to primary care providers are addressed, including guidance to help them decide when to collaborate with, or refer patients to, rheumatology and nephrology specialists based on the severity of gout and CKD.
慢性肾脏病（CKD）是一种合并症，根据最近的估计，痛风性关节炎患者中有47%至54%受其影响。然而，痛风性关节炎合并CKD患者的随机对照试验数据有限，目前的痛风性关节炎治疗指南并未涉及管理这一患者群体所面临的挑战。非甾体抗炎药和秋水仙碱被推荐为急性痛风性关节炎发作的一线治疗药物。然而，对于CKD患者，不推荐使用非甾体抗炎药，因为其使用可能会加重或导致急性肾损伤。此外，CKD患者秋水仙碱的毒性会增加，需要根据肾功能水平减少剂量。别嘌醇、非布司他和聚乙二醇化尿酸酶都是治疗急性发作后控制尿酸水平升高的有效药物。然而，对于CKD患者，所需的别嘌醇剂量减少可能会限制疗效；聚乙二醇化尿酸酶在这一人群中需要进一步研究，非布司他尚未在肌酐清除率<30 mL/min的患者中进行研究。本文综述了目前用于治疗急性和慢性痛风性关节炎的药物（包括CKD患者的降尿酸治疗）相关的风险和益处。文中还讨论了初级保健提供者面临的特殊挑战，包括指导他们根据痛风和CKD的严重程度决定何时与风湿病和肾脏病专家合作或转诊患者。
