Letter to the editor regarding "urate-lowering therapy for patients with gout on hemodialysis".

Abstract

With great interest, we read the article by Alkilany et al.1 The authors reported on the use of urate-lowering therapies (ULTs) in patients with gout and end-stage renal disease (ESRD) on hemodialysis (HD) and observed the uric acid (UA) levels before and after HD initiation.1 We appreciate the authors' contribution in investigating gout and ESRD and add on knowledge to our previous work.2-5 Although the authors did consider many variables that may affect the result of the study, we would like to further discuss some concerns.6 First, the study sample composed of 21 patients with gout and ESRD, the patients took different types of uric acid-lowering therapy, such as allopurinol, febuxostat, pegloticase, losartan, and so forth.1 Treatment with different drugs would have different effects. For example, some studies have shown that febuxostat is more effective than allopurinol in reducing the serum UA (sUA) concentration below 6 mg/dL,7 so we suggest the authors could discuss more on the effect of different ULTs. Second, according to the authors' observations, more than half of the patients on allopurinol had their medication stopped after the initiation of HD.1 However, the low dose of allopurinol and low persistence (the length of time from starting to stopping treatment) are the main reasons for uncontrolled gout.8 Therefore, we recommend that the authors could describe the reason for drug discontinuation and further investigate whether gout flares recurred after they discontinued ULTs. Finally, we highly appreciate the work by the authors for researching the use of ULTs and UA levels in patients with gout and ESRD on HD.1 In addition, the authors also mention that very low UA levels may increase risk of cardiovascular mortality, which is contrary to our general perception.9, 10 We suggest the authors could cite relevant references to support this viewpoint. The authors declare no conflicts of interest.