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Ramírez-Guerrero G, Ronco C, Reis T. Chronic Kidney Disease-Associated Pruritus: Nomenclature and Treatment - We Need to Take Two Steps Forward. Blood Purif 2023; 52:821-823. [PMID: 37666218 DOI: 10.1159/000533469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/01/2023] [Indexed: 09/06/2023]
Affiliation(s)
- Gonzalo Ramírez-Guerrero
- International Renal Research Institute of Vicenza (IRRIV Foundation), Vicenza, Italy,
- Critical Care Unit, Carlos Van Buren Hospital, Valparaíso, Chile,
- Dialysis and Renal Transplant Unit, Carlos Van Buren Hospital, Valparaíso, Chile,
- Department of Medicine, Universidad de Valparaíso, Valparaíso, Chile,
| | - Claudio Ronco
- International Renal Research Institute of Vicenza (IRRIV Foundation), Vicenza, Italy
- Department of Nephrology, Dialysis and Kidney Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Thiago Reis
- International Renal Research Institute of Vicenza (IRRIV Foundation), Vicenza, Italy
- Laboratory of Molecular Pharmacology, Faculty of Health Sciences, University of Brasilia, Brasília, Brazil
- Department of Nephrology and Kidney Transplantation, Fenix Group, São Paulo, Brazil
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Jha CM, Dastoor HD, Gopalakrishnan N, Holt SG. Obstacles to Early Diagnosis and Treatment of Pruritus in Patients with Chronic Kidney Disease: Current Perspectives. Int J Nephrol Renovasc Dis 2022; 15:335-352. [PMID: 36510564 PMCID: PMC9739055 DOI: 10.2147/ijnrd.s294147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 11/15/2022] [Indexed: 12/12/2022] Open
Abstract
Chronic kidney disease-associated pruritus (CKD-aP) is a common condition amongst patients with advanced chronic kidney disease (CKD). Several studies have confirmed that more than four out of ten early-stage CKD patients suffer from this condition, while its prevalence among CKD patients on dialysis reaches up to seven out of ten. It is noted to be associated with other disabling symptoms and serious outcomes. It has significant impact on sleep, mood, daily activities, and quality of life of CKD patients, and increased mortality risk of patients on hemodialysis. The Dialysis Outcomes and Practice Patterns Study found 17% higher mortality among patients with moderate to extreme pruritus compared with patients with no or mild pruritus. Despite its high prevalence, ill-effect, and suffering associated with it, CKD-aP remains surprisingly under-reported on the patient's part and under-recognized by the healthcare team. Even upon being noticed, it remains unattended and poorly treated. Its etiopathogenesis is complex and not fully understood. Many treatment options are available but good quality evidence about most of those is absent, and to date, only two medications are approved for use in this condition. While a validated guideline is very much required for the benefit of the patients and caretakers, further research on several aspects of this issue is required.
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Affiliation(s)
- Chandra Mauli Jha
- SEHA Kidney Care, Abu Dhabi, United Arab Emirates,Correspondence: Chandra Mauli Jha, PO Box 61358; Al Bateen Post Office, Abu Dhabi, United Arab Emirates, Tel +971 50 1096 345; +971 2 55 80 482, Email
| | | | | | - Stephen Geoffrey Holt
- SEHA Kidney Care, Abu Dhabi, United Arab Emirates,Khalifa University, Abu Dhabi, United Arab Emirates
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Elhag S, Rivas N, Tejovath S, Mustaffa N, Deonarine N, Abdullah Hashmi M, Yerneni S, Hamid P. Chronic Kidney Disease-Associated Pruritus: A Glance at Novel and Lesser-Known Treatments. Cureus 2022; 14:e21127. [PMID: 35036239 PMCID: PMC8752116 DOI: 10.7759/cureus.21127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2022] [Indexed: 12/04/2022] Open
Abstract
Chronic kidney disease-associated pruritus (CKD-aP), also known as uremic pruritus, has been associated with increased mortality and lower quality of life among patients with chronic kidney disease (CKD). The relentless nature of the condition is mainly due to its diverse and complex etiologies, which are still being studied. Despite the introduction of many agents to treat it, the resolution rates of CKD-aP still remain unsatisfactory. This study sought to review the lesser-known/novel treatments and establish a relationship between their mechanism of action and the proposed etiologies implicated in CKD-aP. We also discuss the role of dialysis modification in managing CKD-aP. A decent proportion of the reviewed studies have proposed that the agents analyzed in them act through hampering inflammation. Interestingly, the results of two agents alluded to the role of dysbiosis in CKD-aP. The addition of hemoperfusion to the dialysis regimen of patients with CKD-aP improved the severity of their symptoms. The featured treatments could be tried in patients with intractable symptoms. However, additional research is needed to confirm the findings reported in these studies. A better understanding of the pathologic mechanisms is required to help guide the development of agents that can better treat CKD-aP.
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Świerczyńska K, Białynicki-Birula R, Szepietowski JC. Chronic Intractable Pruritus in Chronic Kidney Disease Patients: Prevalence, Impact, and Management Challenges - A Narrative Review. Ther Clin Risk Manag 2021; 17:1267-1282. [PMID: 34876816 PMCID: PMC8643219 DOI: 10.2147/tcrm.s310550] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 11/14/2021] [Indexed: 12/27/2022] Open
Abstract
Chronic kidney disease (CKD) is recognized as a leading public health problem and causes numerous health complications. One of the most common and burdensome dermatological symptoms affecting patients undergoing dialysis is CKD-associated pruritus (CKD-aP). This condition not only has a negative impact on sleep, mood, daily activities, and quality of life but also increases the mortality risk of hemodialyzed patients. Despite that, this condition is greatly underestimated in clinical practice. Due to the complex and still not fully understood etiopathogenesis of CKD-aP, the choice of an effective therapy remains a challenge for clinicians. Most common therapeutic algorithms use topical treatment, phototherapy, and various systemic approaches. This review aimed to summarize most recent theories about the pathogenesis, clinical features, and treatment of CKD-aP.
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Affiliation(s)
- Karolina Świerczyńska
- Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, Wroclaw, Poland
| | - Rafał Białynicki-Birula
- Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, Wroclaw, Poland
| | - Jacek C Szepietowski
- Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, Wroclaw, Poland
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Zhang Q, Henry G, Chen Y. Emerging Role of Transient Receptor Potential Vanilloid 4 (TRPV4) Ion Channel in Acute and Chronic Itch. Int J Mol Sci 2021; 22:7591. [PMID: 34299208 PMCID: PMC8307539 DOI: 10.3390/ijms22147591] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 12/16/2022] Open
Abstract
Itch is a clinical problem that leaves many sufferers insufficiently treated, with over 20 million cases in the United States. This is due to incomplete understanding of its molecular, cellular, and cell-to-cell signaling mechanisms. Transient receptor potential (TRP) ion channels are involved in several sensory modalities including pain, vision, taste, olfaction, hearing, touch, and thermosensation, as well as itch. Relative to the extensive studies on TRPV1 and TRPA1 ion channels in itch modulation, TRPV4 has received relatively little research attention and its mechanisms have remained poorly understood until recently. TRPV4 is expressed in ganglion sensory neurons and a variety of skin cells. Growing evidence in the past few years strongly suggests that TRPV4 in these cells contributes to acute and chronic disease-associated itch. This review focuses on the current experimental evidence involving TRPV4 in itch under pathophysiological conditions and discusses its possible cellular and molecular mechanisms.
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Affiliation(s)
- Qiaojuan Zhang
- Department of Neurology, Duke University, Durham, NC 27710, USA; (Q.Z.); (G.H.)
| | - Gwendolyn Henry
- Department of Neurology, Duke University, Durham, NC 27710, USA; (Q.Z.); (G.H.)
| | - Yong Chen
- Department of Neurology, Duke University, Durham, NC 27710, USA; (Q.Z.); (G.H.)
- Department of Anesthesiology, Duke University, Durham, NC 27710, USA
- Department of Pathology, Duke University, Durham, NC 27710, USA
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Chen Y, Wang ZL, Yeo M, Zhang QJ, López-Romero AE, Ding HP, Zhang X, Zeng Q, Morales-Lázaro SL, Moore C, Jin YA, Yang HH, Morstein J, Bortsov A, Krawczyk M, Lammert F, Abdelmalek M, Diehl AM, Milkiewicz P, Kremer AE, Zhang JY, Nackley A, Reeves TE, Ko MC, Ji RR, Rosenbaum T, Liedtke W. Epithelia-Sensory Neuron Cross Talk Underlies Cholestatic Itch Induced by Lysophosphatidylcholine. Gastroenterology 2021; 161:301-317.e16. [PMID: 33819485 PMCID: PMC9093619 DOI: 10.1053/j.gastro.2021.03.049] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 03/16/2021] [Accepted: 03/22/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND & AIMS Limited understanding of pruritus mechanisms in cholestatic liver diseases hinders development of antipruritic treatments. Previous studies implicated lysophosphatidic acid (LPA) as a potential mediator of cholestatic pruritus. METHODS Pruritogenicity of lysophosphatidylcholine (LPC), LPA's precursor, was examined in naïve mice, cholestatic mice, and nonhuman primates. LPC's pruritogenicity involving keratinocyte TRPV4 was studied using genetic and pharmacologic approaches, cultured keratinocytes, ion channel physiology, and structural computational modeling. Activation of pruriceptor sensory neurons by microRNA-146a (miR-146a), secreted from keratinocytes, was identified by in vitro and ex vivo Ca2+ imaging assays. Sera from patients with primary biliary cholangitis were used for measuring the levels of LPC and miR-146a. RESULTS LPC was robustly pruritic in mice. TRPV4 in skin keratinocytes was essential for LPC-induced itch and itch in mice with cholestasis. Three-dimensional structural modeling, site-directed mutagenesis, and channel function analysis suggested a TRPV4 C-terminal motif for LPC binding and channel activation. In keratinocytes, TRPV4 activation by LPC induced extracellular release of miR-146a, which activated TRPV1+ sensory neurons to cause itch. LPC and miR-146a levels were both elevated in sera of patients with primary biliary cholangitis with itch and correlated with itch intensity. Moreover, LPC and miR-146a were also increased in sera of cholestatic mice and elicited itch in nonhuman primates. CONCLUSIONS We identified LPC as a novel cholestatic pruritogen that induces itch through epithelia-sensory neuron cross talk, whereby it directly activates skin keratinocyte TRPV4, which rapidly releases miR-146a to activate skin-innervating TRPV1+ pruriceptor sensory neurons. Our findings support the new concept of the skin, as a sensory organ, playing a critical role in cholestatic itch, beyond liver, peripheral sensory neurons, and central neural pathways supporting pruriception.
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Affiliation(s)
- Yong Chen
- Department of Neurology, Duke University, Durham, North Carolina.
| | - Zi-Long Wang
- Department of Neurology, Duke University, Durham, North Carolina; Center for Translational Pain Medicine, Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Michele Yeo
- Department of Neurology, Duke University, Durham, North Carolina
| | - Qiao-Juan Zhang
- Department of Neurology, Duke University, Durham, North Carolina
| | - Ana E López-Romero
- Departamento de Neurociencia Cognitiva, Instituto de Fisiología Celular, Universidad Nacional Autónoma de México, Coyoacan, Mexico City, Mexico
| | - Hui-Ping Ding
- Department of Physiology and Pharmacology, Wake Forest University, Winston-Salem, North Carolina
| | - Xin Zhang
- Center for Translational Pain Medicine, Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Qian Zeng
- Department of Neurology, Duke University, Durham, North Carolina
| | - Sara L Morales-Lázaro
- Departamento de Neurociencia Cognitiva, Instituto de Fisiología Celular, Universidad Nacional Autónoma de México, Coyoacan, Mexico City, Mexico
| | - Carlene Moore
- Department of Neurology, Duke University, Durham, North Carolina
| | - Ying-Ai Jin
- Department of Dermatology, Duke University, Durham, North Carolina
| | - Huang-He Yang
- Department of Biochemistry, Duke University, Durham, North Carolina; Department of Neurobiology, Duke University, Durham, North Carolina
| | | | - Andrey Bortsov
- Center for Translational Pain Medicine, Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Marcin Krawczyk
- Department of Medicine II, Saarland University Medical Center, Saarland University, Homburg, Germany; Laboratory of Metabolic Liver Diseases, Center for Preclinical Research, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, Saarland University, Homburg, Germany; Hannover Medical School MHH, Hannover, Germany
| | - Manal Abdelmalek
- Division of Gastroenterology, Department of Medicine, Duke University, Durham, North Carolina
| | - Anna Mae Diehl
- Division of Gastroenterology, Department of Medicine, Duke University, Durham, North Carolina
| | - Piotr Milkiewicz
- Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland; Translation Medicine Group, Pomeranian Medical University, Szczecin, Poland
| | - Andreas E Kremer
- Department of Medicine 1, Gastroenterology, Hepatology, Pneumology and Endocrinology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Jennifer Y Zhang
- Department of Dermatology, Duke University, Durham, North Carolina; Department of Pathology, Duke University, Durham, North Carolina
| | - Andrea Nackley
- Center for Translational Pain Medicine, Department of Anesthesiology, Duke University, Durham, North Carolina; Department of Pharmacology and Cancer Biology, Duke University, Durham, North Carolina
| | - Tony E Reeves
- Department of Internal Medicine, Section on Molecular Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Mei-Chuan Ko
- Department of Physiology and Pharmacology, Wake Forest University, Winston-Salem, North Carolina
| | - Ru-Rong Ji
- Center for Translational Pain Medicine, Department of Anesthesiology, Duke University, Durham, North Carolina; Department of Neurobiology, Duke University, Durham, North Carolina
| | - Tamara Rosenbaum
- Departamento de Neurociencia Cognitiva, Instituto de Fisiología Celular, Universidad Nacional Autónoma de México, Coyoacan, Mexico City, Mexico
| | - Wolfgang Liedtke
- Department of Neurology, Duke University, Durham, North Carolina; Center for Translational Pain Medicine, Department of Anesthesiology, Duke University, Durham, North Carolina; Department of Neurobiology, Duke University, Durham, North Carolina; Neurology Clinics for Headache, Head-Pain and Trigeminal Sensory Disorders, Duke University, Durham, North Carolina; Clinics for Innovative Pain Therapy, Department of Anesthesiology, Duke University, Raleigh, North Carolina.
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