Pruritus in Kidney Disease

Abstract

Summary Pruritus is a common and distressing symptom in patients with chronic kidney disease. The most recent epidemiologic data have suggested that approximately 40% of patients with end-stage renal disease experience moderate to severe pruritus and that uremic pruritus (UP) has a major clinical impact, being associated strongly with poor quality of life, impaired sleep, depression, and increased mortality. The pathogenesis of UP remains largely unclear, although several theories on etiologic or contributing factors have been proposed including increased systemic inflammation; abnormal serum parathyroid hormone, calcium, and phosphorus levels; an imbalance in opiate receptors; and a neuropathic process. UP can present somewhat variably, although it tends to affect large, discontinuous, but symmetric, areas of skin and to be most symptomatic at night. A variety of alternative systemic or dermatologic conditions should be considered, especially in patients with asymmetric pruritus or other atypical features. Treatment initially should focus on aggressive skin hydration, patient education on minimizing scratching, and optimization of the aspects of chronic kidney disease care that are most relevant to pruritus, including dialysis adequacy and serum parathyroid hormone, calcium, and phosphorus management. Data for therapy specifically for UP remain limited, although topical therapies, gabapentin, type B ultraviolet light phototherapy, acupuncture, and opioid-receptor modulators all may play a role.

Chronic kidney disease-associated pruritus: impact on quality of life and current management challenges

“…4 It has been postulated that creams that rehydrate dry skin (emollients) may improve itching. 71 Several different formulations of emollient creams have been studied in patients with CKD-aP.…”

“…72 Several additional non-controlled trials have also shown the beneficial effects of compounds containing emollient creams in patients with xerosis and CKD-aP. 71,[73][74][75][76] In a prospective clinical trial, 200 g of a aqueous cream applied twice daily significantly improved pruritus severity in 16 out of 21 recruited dialysis patients and resulted in the abatement of itching in 9 patients. 75 In a prospective study of 21 HD patients, all treated with structured physiological lipids and endogenous cannabinoids twice daily for 3 weeks, pruritus severity was significantly reduced at the end of the treatment period and pruritus completely abated in 8 of 21 participants.…”

Sleep Disorders, Restless Legs Syndrome, and Uremic Pruritus: Diagnosis and Treatment of Common Symptoms in Dialysis Patients

“…They are not recommended in recent reviews. 71,72 Crucially, a recent functional magnetic resonance imaging study revealed that in uremic pruritis, the central transmission of itch is via a non-histaminergic pruritus pathway and not a histaminergic pathway. 85 These medications have sedating effects, which are especially risky in the older and frailer ESRD population.…”

“…72–74,77–80,82,85–93,95,96 BUN, blood urea nitrogen; GFR, glomerular filtration rate; PTH, parathyroid hormone; UP, uremic pruritus.…”

Comparison of high-flux hemodialysis with hemodialysis filtration in treatment of uraemic pruritus: a randomized controlled trial

“…Various pathophysiological mechanisms for UP have been proposed in recent years, including hypervitaminosis A, skin xerosis, hyperparathyroidism, histamine binding to the H4 receptor, iron deficiency, elevated levels of histamine, homeostasis unbalance in phosphate, magnesium and calcium [7]. It is also identified to be a complex condition whereby opioids, mast cells, elevated skin surface pH and some components in dialysis membranes are recognized as pathogen for UP [8].…”