My husband has uremia-related gout in his ankles. Has anyone else had to deal with this? Any solutions that aren’t contraindicated with renal failure? The pain is just awful and it seems like the doctors are treating him like he’s drug-seeking since they can find no break in the bone and aren’t nephrologists so they don’t understand what’s going on. His nephrologist doesn’t want to prescribe anything for this because he’s not an ortho. Where we live it can take weeks to get an ortho appointment and this level of pain is just not going to wait that long. Any suggestions would be extremely helpful. (I’m shocked at how little your average primary care doctor knows about renal failure and all the ‘wonderful’ bells and whistles that go along with it.) Sure makes it hard to get appropriate treatment. :?

Hi Mathis, and welcome to Home Dialysis Central. I’m surprised to hear that your husband’s nephrologist doesn’t feel comfortable prescribing gout medication for him. Gout is a not-uncommon side effect of kidney disease (sometimes a cause of kidney failure in its own right). It’s usually treated as an Internal Medicine (nephrologists are Internists) condition, not an orthopedic one. I wonder if a new nephrologist might be in order? Just a thought…

Anyway, here’s a general nursing article that was posted to the Dialysis_support email list about gout. It has some general background that you may find helpful–but was based on an article from 1997, so there may be newer drugs/treatments that are not mentioned here. I hate to think of your husband being in so much pain. :frowning:

[b] Clinical Snapshot GOUT

Recognizing this painful but treatable condition[/b]
By Denise T Bynum, MSN, FNP

"Gout is a disorder in purine metabolism characterized by elevated serum uric acid concentrations (hyperuricemia), the formation of monosodium urate crystal deposits in joints and surrounding soft tissue, and acute attacks of arthritis.

Gout may develop from a primary genetic metabolic defect that causes overproduction or decreased renal excretion of uric acid, or secondary to disease or medication. As uric acid is released into plasma and body fluids, the system becomes supersaturated and renal excretion isn’t possible. In a process not fully understood, the excess uric acid crystallizes. These crystals infiltrate joints, and an inflammatory response ensues.

About 95% of those with primary gout are men. The first attack typically occurs between the ages of 40 and 50. Since estrogen expedites renal excretion of uric acid, gout is uncommon in premenopausal women. Only 10% to 20% of patients have a family history of gout.

Assessment Findings

Gout progresses in three clinical stages. In stage one, asymptomatic hyperuricemia, the only telltale sign is a serum uric acid level of over 7 mg/dL (normal for men is 5 +/- 1 mg/dL; normal for women 4 +/- 1 mg/dL).

Hyperuricemia advances to stage two, acute gouty arthritis, in only 20% of patients. This stage is characterized by an inflammatory reaction in a single joint (usually in a big toe). Its onset is sudden, often occurring during the night or early morning. The affected area becomes swollen and painful. The patient may have a fever and an elevated WBC count.

Untreated, an acute attack may resolve within hours or persist for several days. Some people never have a second attack. Others experience several acute attacks, interrupted by asymptomatic intervals called ‘intercritical periods’, which may last for several months or several years and diminish as the disease progresses. Acute attacks may be triggered by trauma, drugs, stress, or alcohol.

If the urate pool continues to expand, the disease progresses to the third stage, ‘chronic gout’, which is marked by continual inflammation due to urate crystal deposits called ‘tophi’, in cartilage, subchondral bone, synovial membranes, tendons, and soft tissue. Most common are the helix of the ear, olecranon bursa, Achilles tendon, prepatellar bursa, and extensor surface of the forearm. Joints are painful, swollen, and stiff. Uric acid kidney stones form in 20% to 30% of patients, putting them at risk for renal infection or obstruction.

If your patient’s serum uric acid levels are elevated, a 24-hour urine sample (collected while the patient is on a purine-free diet) will reveal
whether the problem is overproduction or impaired renal secretion of uric acid. Since tophi may resemble the nodules of rheumatoid arthritis, a rheumatoid factor titer may be ordered. For a definitive diagnosis, synovial fluid is aspirated from the affected joint to confirm the presence of uric acid crystals.

Plan of care

Protect affected areas from trauma, including the weight of bed linens

Cold applications and joint immobilization may be helpful. Symptoms respond fairly quickly to colchicine (typically 48 hours after oral treatment or 12 hours after iv infusion), which decreases inflammation by inhibiting the production and release of phagocytic leukocytes.

Nonsteroidal anti-inflammatory drugs NSAIDS) may be substituted and have fewer adverse gastrointestinal effects. When a single joint is involved and the patient can’t tolerate colchicine or NSAIDS, corticosteroids may be injected into the affected joint. Allopurinol may be prescribed to reduce uric acid production; probenecid is used to promote excretion of uric acid by inhibiting renal tubular reabsorption.

Patient teaching points

Avoid salicylates (for example, aspirin and diflunisal) and diuretics because they block renal excretion of uric acid.

To prevent uric acid buildup, limit consumption of purine-rich foods (for example, organ meats) and alcohol, and drink up to 2 L of fluid per day.

If obese, lose weight.

Have uric acid levels tested annually.

Denise T Bynum is a nurse practitioner at Senatobia Community Hospital and Sardis Family Practices Clinic, and an associate degree nursing instructor at Northwest Mississippi Community College, Senatobia, MS."

(Cite: American Journal of Nursing (AJN), July 1997. Pgs. 36-37)


I have the big toe gout. It started about four years before I started dialysis. My primary prescribed indocin and tylenol 3, indocin is a nonsteroidal anti inflammetory. Indocin does have a warning on it for kidney patients, but apparently the pain I was in overroad that warning and it was prescribed in a very small dose. The tylenol 3 hardly helped at all except to make me sleepy and still in pain. Once the acute attack was over (about a week) I started taking allopurinal, and I broke out in head to toe hives the next day. So that left colchicine daily which my doctor was not happy about having me on but it seemed to do the trick. I did not go to ortho, my primary put me on the medication and my nephrologist agreed. Since starting dialysis my uric acid level has dropped and I have been weaned off the colchicine. One less pill to take always makes me happy!

Please ask your primary care physician to do a little research on it and do what he/she can to help you, I know that pain is horrible.

Thanks for the information. On Monday, I called his PCP and got a Rx for prednisone and by Tuesday, he was again able to walk. It seems like this attack (at least the worse of it) is over…I’m still running into this frustrating scenario where he needs help NOW and every doctor is afraid to help because they’re afraid they’ll do something contraindicative or what the other discipline is doing.
Neph doesn’t want to help with nausea he experiences with dialysis, or gout.
PCP doesn’t want to help with much of anything because he’s afraid he’ll do the wrong thing.
I don’t know how to get through this patch, Any suggestions!

Is your husband on dialysis or does he have kidney damage but not kidney failure? Most of the time nephrologists like to manage or approve every medicine that a dialysis patient takes. I’m surprised that your husband’s nephrologist doesn’t seem to want to do this. If your husband is nauseated, it could be because toxins are high in his blood. If he’s on dialysis, he may not be getting enough dialysis. If he has kidney damage, the damage may be worsening.

You might want to read this booklet on gout that includes what it is, treatments, tips to follow to reduce flare ups, etc. I’d show this booklet to the nephrologist and ask if any of the treatments you haven’t tried might help. If your husband isn’t on dialysis yet, be aware that research has shown that NSAIDs can make kidney problems worse so I’d try other things first.

Has anyone suggested changes in diet and medications? Some medicines may make gout worse and eating foods that are high in purines increase uric acid production. Here’s a website that has safe foods for people with gout:

My husband is a 33 yo ESRD patient relatively new to PD.
I wish the neph would manage his medications. All the Neph prescribes for him is Hectoral and Lasix (which makes the gout worse).

It seems the neph has this attitude that if it’s not STRICLY renal in nature, he shouldn’t deal with it. When hubby complains to him about nausea for instance, he tells him he needs an EGD esophagram with a gastro doc. Yet, everything I’ve read leads me to believe that nausea is not strictly uncommon in PD patients, depending on how their cath lays.

Hubby also has groin pain with treatments, so neph says he needs to see urologist, again, probably a matter of cath placement or dialysite flow.

We’re not going through a lot of expensive, unnecessary and uncomfortable testing just because this guy seems single-minded. Hubby had an upper and lower GI a few years ago, and everything is fine.

For the gout pain, he wants him to see an orthopaedist. Which could take weeks and we’re willing to go, but how much pain should he be in in the meantime? Also, wouldn’t a Rheumatologist make more sense for gout, anyway?

Sometimes I think this guy gets paid ‘per referral’! :slight_smile:

Does your husband have other nephrologist options where you live who would be covered by your insurance? Even if you choose not to avail yourself of them, knowing that you have options may ease some of your frustration–because at least then you’re choosing to stay with a doctor who isn’t meeting your husband’s needs.

It’s possible that the catheter not in the correct place causing pain and/or not allowing all the fluid to drain off. A displaced cathether can be found by x-ray. A urologist could find if your husband has an infection in his urinary tract, but I’m not sure that this specialty would be the best to find a catheter that was not where it’s supposed to be.

So far as gout, I’d suggest that your husband see a rheumatologist. They deal with arthritis and other similar conditions and know much more about new treatments for people with gout. If he’s tried all the medicines that are usually used – nonsteroidal anti-inflammatory drugs (NSAIDs), prednisone, and colchicine (used in the first 12 hours), he might be interested in participating in a clinical trial. You can read about clinical trials at:

So far as his GI tract, even if he had a perfect GI tract a few years ago, he could have developed polyps or diverticuli which are small pouches in the intestine that can get infected causing a condition called diverticulosis.

As others have written, you might want to consider all options for nephrologists in your area if you’re not satisfied with the care his nephrologist is providing. In most cases, people do have choices.