Management of hyperuricemia and gout in CKD.

A 55-year-old man with history of kidney transplantation years ago because of diabetic nephropathy has severe ophaceous gout. He has been unable to tolerate treatment ith allopurinol because of worsening skin rashes. His last erum creatinine level was 2.3 mg/dL (203.3 mol/L). urrent medications include tacrolimus, mycophenolate ofetil, and prednisone at a dose of 20 mg/d orally. He resents to the emergency department with red, hot, swollen, nd painful knees and wrists. His temperature is 99.5°F, outy tophi are evident in the hands, and a peripheral-blood hite blood cell count is 12.5 10/ L with 90% polymorhonuclear leukocytes without band forms. An aspirate of ne of his knees shows 40,000 nucleated cells with 50% olymorphonuclear leukocytes. Abundant intracellular negaively birefringent needle-shaped crystals are observed uner polarized microscopy.