Effects of Uremic Clearance Granules in Uremic Pruritus: A Meta-Analysis

Uremic pruritus is common among patients with advanced or end-stage renal disease, with an incidence of >40% among patients on dialysis. Uremic clearance granules (UCGs) are effective in managing uremic pruritus and delay the progression of chronic kidney disease. We conducted a systematic review and a meta-analysis to evaluate the efficacy of UCG in patients with uremic pruritus. Several electronic databases were searched systematically from their inceptions until 19 July 2021. Randomized control trials evaluating the efficacy of UCG in patients with uremic pruritus were selected. Eleven trials including 894 participants were published between 2011 and 2021. Patients administered UCGs had a significantly decreased visual analog scale score (mean difference [MD], -2.02; 95% confidence interval [CI], -2.17 to -1.88), serum levels of hsCRP (MD, -2.07 mg/dL; 95% CI, -2.89 to -1.25; p < 0.00001), TNF-α (MD, -15.23 mg/L; 95% CI, -20.00 to -10.47; p < 0.00001]), β2-MG (MD, -10.18 mg/L; 95% CI, -15.43 to -4.93; p < 0.00001), and IL-6 (MD, -6.13 mg/L; 95% CI, -7.42 to -4.84; p < 0.00001). In addition, UCGs significantly reduced serum levels of creatinine, BUN, PTH, iPTH, phosphorus, and the overall effectiveness rate. UCGs could be an attractive complementary therapy for patients with uremic pruritus.

Effect of sertraline on uremic pruritus improvement in ESRD patients

Background. Although uremic pruritus is a common and upsetting problem of chronic kidney disease, there is no approved treatment for it. This study was undertaken to find the efficiency of sertraline as a possible treatment for uremic pruritus. Methods. 19 ESRD patients under hemodialysis with severe chronic pruritus were randomly selected to participate in this before-after clinical trial. Before and after starting treatment with sertraline, a detailed pruritus history was obtained and pruritus graded by the 30-item inventory of pruritus that patients based on priorities grade allocated to 3 classes. Subjects were treated with sertraline 50 mg oral daily for four months, with monthly assessments of pruritus symptoms. Results. Before treatment with sertraline, the grade of pruritus in 9 (47.4%) patients was moderate and severe in 10 (52.6%) patients. After treatment, grade of pruritus in 11 (57.8%) patients was weak, 6 (31.5%) have moderate and only 2 (10.7%) patients have severe pruritus. Of 10 patients with severe pruritus, 5 (50%) patients experiencing weak pruritus, and 4 (40%) patients have moderate pruritus after treatment. Based on Wilcoxon signed-rank test, the difference between the grade of pruritus before and after treatment with sertraline was significant (P = 0.001). Conclusions. Although no definitive recommendation can be made regarding treatment of uremic pruritus, we found an increased antipruritic effect of sertraline in ESRD patients.

Cutaneous manifestations in end-stage renal disease

The prevalence of chronic kidney disease has increased over the last years. The effects of this disease are complex and may lead to dysfunction of multiple organs, including the skin, with most patients presenting with at least one dermatologic alteration. Sometimes these symptoms can be the first clear sign of kidney disease. This article discusses the skin manifestations related to severe renal impairment or end-stage renal disease (ESRD), which are divided into nonspecific and specific, and reviews the clinical features, etiopathogenesis and therapeutic options for these dermatoses. Early recognition and treatment reduce morbidity and improve these patients' quality of life.

Treatment of uremic pruritus with narrowband ultraviolet B phototherapy: an open pilot study

We report the results of a pilot study of narrowband ultraviolet B phototherapy for the treatment of 20 patients with uremic pruritus. Ten patients completed the 6-week study period. A total of 8 patients were found to be responders. Of the remaining 10 patients who left the study before 6 weeks, 6 were satisfied with the response. In the follow-up period, 7 responders could be examined, and 3 were in remission 6 months after completing treatment. However, pruritus recurred in the remaining 4 responders. Narrowband ultraviolet B phototherapy may be an effective treatment for patients with uremic pruritus. Recurrence of pruritus, however, is a frequent problem.

Baseline serum levels of mast cell tryptase are raised in hemodialysis patients and associated with severity of pruritus

BACKGROUND

The pathogenesis of pruritus in renal disease is not yet understood. Evidence suggests that mast cells play a role; for example, the number of dermal mast cells is increased in patients on hemodialysis.

PATIENTS AND METHODS

To investigate a possible role of mast cell tryptase in pruritus of patients undergoing chronic hemodialysis, serum mast cell tryptase concentrations were measured in blood samples taken from 93 such patients, 53 of whom also recorded the severity of their pruritus on a visual analogue scale.

RESULTS

Serum mast cell tryptase levels were above 11.4 microg/l (95th percentile) in 84 of 93 hemodialysis patients (90.3 %). The intensity of pruritus correlated significantly (p = 0.014) with the tryptase levels, an associated not yet shown for other mast cell-related parameters.

CONCLUSIONS

Mast cells or even tryptase itself may be involved in the pathogenesis of pruritus of hemodialysis patients.

Pruritus in hemodialysis patients

Background

Pruritus is one of the most bothersome symptoms in patients on maintenance hemodialysis (HD), however little progress is seen in our understanding of its pathogenesis. The aim of this study was to evaluate the frequency of pruritus in HD patients in Tehran, Iran, and to correlate its presence and intensity with relevant clinical and laboratory parameters.

Methods

One hundred sixty-seven patients on maintenance HD at three out-patient HD units were enrolled in the study. Itch intensity was scored as mild, moderate and severe. Some relevant clinical and laboratory parameters (age, sex, xerosis, presence of neuropathy, duration of dialysis, history of atopy and laboratory findings including hematocrit, creatinine, urea, calcium, phosphorus, parathyroid hormone [PTH] and alkaline phosphatase) were evaluated.

Results

Pruritus was found in 41.9% of patients. The intensity of itching was mild, moderate and severe, in 51.4%, 11.4% and 37.7% of patients, respectively. In 22 patients (31.4%) pruritus intensified during and after dialysis. There was no significant difference in the serum levels of creatinine, blood urea nitrogen, calcium, phosphorus, alkaline phosphatase, PTH and hematocrit between patients with and without pruritus. Age, sex, xerosis, underlying renal disease, history of atopy and duration of haemodialysis were not significantly different between the two groups. However, neuropathy was significantly more common in the pruritic group (63.8% versus 42.1%) (pv = 0.006).

Conclusion

Clinical neuropathy was the only significant finding in the pruritic group in our study. This finding justifies further research on nerve function and neurotransmitters in hemodialysis patients and the introduction of new drugs targeting neuropathy.

A prospective proof of concept study of the efficacy of tacrolimus ointment on uraemic pruritus (UP) in patients on chronic dialysis therapy

BACKGROUND

Uraemic pruritus (UP) is a serious symptom of chronic dialysis patients and patients with end-stage renal disease. UP causes skin damage, discomfort, sleeping disorders and diminished quality of life. Since UP is considered to be in part an immune-mediated inflammatory process, immunosuppressive drugs like tacrolimus may be beneficial.

METHODS

We conducted a prospective study on the effect of 6 weeks treatment with two sequential concentrations of tacrolimus ointment on the severity of UP in chronic dialysis patients and again after 2 weeks wash-out. Twenty-five patients with UP were enrolled in the study; 21 patients completed the study. UP was measured using a validated modified pruritus assessment score and a Visual Analogue Scale (VAS).

RESULTS

The modified pruritus assessment score decreased significantly by 81.8% after 6 weeks treatment from [median score 11 (interquartile range: IQR 6-16) on day 0 to median score 2 (IQR 0-5.25) at week 6: P<0.0001]. After 2 weeks wash-out, the median score returned to 72.7% of baseline levels [8 (IQR 2-16)]. Using the VAS score an identical evolution could be demonstrated. Tacrolimus ointment was well tolerated and no serious adverse events were noted. Transient stinging and burning sensation was reported by four patients in the first weeks of the trial, one patient suffered a mild skin rash. No systemic exposure to tacrolimus was detected.

CONCLUSION

This prospective study has shown that 6 weeks treatment with tacrolimus ointment significantly reduces the severity of UP in chronic dialysis patients and is well tolerated. Randomized placebo-controlled studies are necessary to confirm these encouraging preliminary results.