Target Serum Urate and CKD Progression in Gout
A cohort study published in JAMA Internal Medicine finds that achieving guideline-recommended target serum urate levels (<6 mg/dL) with urate-lowering therapy (ULT) is not associated with accelerated chronic kidney disease (CKD) progression in patients with gout and CKD stage 3. The study, led by researchers from Central South University of Changsha, China), the University of Auckland in New Zealand), and other international centers, used UK general practice data from 2000–2023 to emulate a target trial and inform clinical practice.
Study Findings / Main News
The analysis included 14,792 adults (mean age 73.1 years; 62.3% men) with gout and CKD stage 3 (eGFR 30–60 mL/min/1.73 m²) drawn from the UK IQVIA Medical Research Database. Investigators compared outcomes between individuals who achieved a serum urate <6 mg/dL within one year of initiating ULT and those who did not.
Over a mean follow-up of ~3.3 years, the 5-year risk of severe or end-stage kidney disease was 10.32% among patients achieving target serum urate versus 12.73% in those who did not. After adjustment, achieving the target was associated with a hazard ratio (HR) of 0.89 (95% CI, 0.80–0.98) for progression to severe or end-stage CKD, with a −2.41% absolute risk difference (95% CI, −4.61% to −0.21%). End-stage disease alone was also less frequent (HR, 0.67; 95% CI, 0.46–0.97).
Authors note that ~98.8% of ULT prescriptions were allopurinol and emphasize that lowering urate to guideline targets did not increase the risk of kidney disease progression. “These findings support a treat-to-target strategy in clinical practice,” they state, addressing longstanding clinician concerns about ULT use in patients with impaired renal function.
Clinical Implications
This evidence is important for rheumatologists, nephrologists, and primary care physicians managing patients with gout complicated by CKD stage 3. Historically, providers often hesitated to optimize ULT due to fears of worsening kidney function. However, the study suggests that achieving recommended serum urate targets (<6 mg/dL) is well tolerated and may correlate with lower rates of profound CKD progression compared with suboptimal urate lowering.
The results align with professional guideline recommendations advocating a treat-to-target approach for gout management. They provide real-world support that ULT, primarily allopurinol, can be safely pursued without accelerating CKD progression. Clinicians should balance the benefits of reducing gout flares and urate burden with careful monitoring, particularly in patients with multiple comorbidities and advanced age.
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.
