Urate-Lowering Therapy Does Not Increase Kidney Disease Risk in Patients With Gout

A new study examining nearly 15,000 patients with gout and chronic kidney disease (CKD) stage 3 found that achieving a serum urate level below 6 mg/dL through urate-lowering therapy (ULT) does not increase the risk of severe or end-stage kidney disease progression.

Current guidelines from the American College of Rheumatology and the European Alliance of Associations for Rheumatology recommend treating gout to a target serum urate level below 6 mg/dL to prevent flares and long-term complications. However, these targets are often not met in clinical practice, with concerns about kidney function being a contributing factor to underuse of ULT.

The study, which analyzed data from the IQVIA Medical Research Database between 2000 and 2023, included patients aged 40 to 89 years with both gout and CKD stage 3. Researchers compared two groups: those who achieved the target serum urate level of less than 6 mg/dL within one year of initiating ULT and those who did not. The primary outcome was the progression of CKD to severe or end-stage disease, defined as an estimated glomerular filtration rate (eGFR) below 30 mL/min/1.73 m² on at least two occasions more than 90 days apart or a diagnosis of CKD stage 4 or 5, dialysis, or kidney transplant.

At the 5-year follow-up, the risk of severe or end-stage kidney disease was 10.32% in the group that achieved the target serum urate level compared with 12.73% in those who did not. The adjusted 5-year risk difference was −2.41% (95% CI, −4.61% to −0.21%), and the adjusted hazard ratio (HR) was 0.89 (95% CI, 0.80 to 0.98). The upper boundary of the 95% CI remained below the prespecified noninferiority margin (HR = 1.2), indicating that lowering serum urate below 6 mg/dL was not associated with an increased risk of kidney disease progression.

As an observational study, the researchers noted a possibility of residual confounding. Patients who achieved the target urate level may have had better health care access, adherence, or monitoring, which could have influenced the results. Additionally, the study focused on patients with CKD stage 3, meaning the findings may not be applicable to those with more advanced kidney disease.

“Our study raises an important question about whether the risk-benefit assessment of a treat-to-target approach with ULT should be reevaluated for patients with gout and CKD in light of this evidence,” the researchers wrote.

Reference
Wang Y, Dalbeth N, Terkeltaub R, et al. Target serum urate achievement and chronic kidney disease progression in patients with gout and kidney disease. JAMA Intern Med. 2025;185(1):74-82. doi:10.1001/jamainternmed.2024.6212