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Marcello M, Marturano D, Ronco C, Zanella M. The role of blood purification therapies in the treatment of chronic kidney disease-associated pruritus: a systematic review. Clin Kidney J 2024; 17:sfae266. [PMID: 39319306 PMCID: PMC11420667 DOI: 10.1093/ckj/sfae266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2024] [Indexed: 09/26/2024] Open
Abstract
Chronic kidney disease-associated pruritus (CKD-aP) is a common complication in dialysis patients which is not fully addressed by pharmacological and dialytic therapy. The objective was to review the literature on the effects of extracorporeal blood purification modalities on CKD-aP. The population comprised patients aged ≥18 years on chronic dialysis. PubMed, Embase, and Medline were systematically searched until February 2024 for clinical studies comparing the effect of different dialysis modalities on pruritus intensity. Two reviewers extracted data independently. Risk of bias for randomized controlled trials (RCTs) was assessed using the Cochrane tool. Any extracorporeal blood purification therapy for the treatment of CKD-aP was included. Outcome was quantitative change in pruritus intensity on a validated itching scale. This review included eight RCTs examining five different dialysis modalities, three observational studies examining three dialysis modalities, and six prospective clinical trials assessing four dialysis modalities. These treatments included peritoneal dialysis, low-flux and high-flux dialysis, hemodiafiltration, expanded hemodialysis, hemadsorption, hemodiafiltration with endogenous reinfusion and dialysis with polymethylmethacrylate membrane. Risk of bias was high in most studies. The largest body of evidence was found for the efficacy of hemadsorption. Limitations of evidence included heterogeneity in diagnostic tools and treatment, risk of selection bias, small sample sizes and short follow-up durations that made it challenging to perform a robust systematic review and meta-analysis. Despite the high prevalence of pruritus among dialysis patients, current evidence for efficacy of standard dialytic treatment is weak. The only technique that appears to be effective is hemoadsorption alone or coupled with hemodialysis. More high-quality studies are needed to confirm the long-term benefits.
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Affiliation(s)
- Matteo Marcello
- Department of Nephrology, Dialysis and Trasplantation, San Bortolo Hospital, Vicenza, Italy
- International Renal Research Institute Vicenza, IRRIV, Vicenza, Italy
| | - Davide Marturano
- Department of Nephrology, Dialysis and Trasplantation, San Bortolo Hospital, Vicenza, Italy
- International Renal Research Institute Vicenza, IRRIV, Vicenza, Italy
| | - Claudio Ronco
- International Renal Research Institute Vicenza, IRRIV, Vicenza, Italy
| | - Monica Zanella
- Department of Nephrology, Dialysis and Trasplantation, San Bortolo Hospital, Vicenza, Italy
- International Renal Research Institute Vicenza, IRRIV, Vicenza, Italy
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Rigatto C, Collister D, Granger-Vallée A, Girard L, Hingwala J, Karaboyas A, Levin A, McFarlane P, Pisoni R, Prasad B, Proulx N, Schwartz D, Sood M, Suri R, Tennankore K. Pathways for Diagnosing and Treating CKD-Associated Pruritus: A Narrative Review. Can J Kidney Health Dis 2024; 11:20543581241238808. [PMID: 38680970 PMCID: PMC11047256 DOI: 10.1177/20543581241238808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 02/14/2024] [Indexed: 05/01/2024] Open
Abstract
Purpose of Review Chronic kidney disease (CKD)-associated pruritus is a common, persistent, and distressing itch experienced by patients across the CKD spectrum. Although the disorder is associated with adverse outcomes and poor health-related quality of life, it remains underdiagnosed and undertreated. The purpose of this narrative review is to offer health care providers guidance on how to effectively identify, assess, and treat patients with CKD-associated pruritus, with the goal of reducing symptom burden and improving patient-important outcomes, such as quality of life (QoL). Sources of Information A panel of nephrologists and researchers from across Canada and the United States was assembled to develop this narrative review based on the best available data, current treatment guidelines, and their clinical experiences. Methods A panel of nephrologists who actively care for patients with pruritus receiving dialysis from across Canada was assembled. Two researchers from the United States were also included based on their expertise in the diagnosis and management of CKD-associated pruritus. Throughout Spring 2023, the panel met to discuss key topics in the identification, assessment, and management of CKD-associated pruritus. Panel members subsequently developed summaries of the pertinent information based on the best available data, current treatment guidelines, and added information on their own clinical experiences. In all cases, approval of the article was sought and achieved through discussion. Key Findings This narrative review provides pragmatic guidance addressing: (1) methods for screening CKD-associated pruritus, (2) assessing severity, (3) management of CKD-associated pruritus, and (4) suggested areas for future research. The panel developed a 3-pillar framework for proactive assessment and severity scoring in CKD-aP: systematic screening for CKD-associated pruritus (pillar 1), assessment of pruritus intensity (pillar 2), and understanding the impact of CKD-associated pruritus on the patient's QoL (pillar 3). Management of CKD-associated pruritus can include ensuring optimization of dialysis adequacy, achieving mineral metabolism targets (ie, calcium, phosphate, and parathyroid hormone). However, treatment of CKD-associated pruritus usually requires additional interventions. Patients, regardless of CKD-associated pruritus severity, should be counseled on adequate skin hydration and other non-pharmacological strategies to reduce pruritus. Antihistamines should be avoided in favor of evidence-based treatments, such as difelikefalin and gabapentin. Limitations A formal systematic review (SR) of the literature was not undertaken, although published SRs were reviewed. The possibility for bias based on the experts' own clinical experiences may have occurred. Key takeaways are based on the current available evidence, of which head-to-head clinical trials are lacking. Funding This work was funded by an arm's length grant from Otsuka Canada Pharmaceutical Inc. (the importer and distributer of difelikefalin in Canada). LiV Medical Education Agency Inc. provided logistical and editorial support.
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Affiliation(s)
- Claudio Rigatto
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - David Collister
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
- Chronic Disease Innovation Centre, Winnipeg, MB, Canada
| | | | - Louis Girard
- Division of Nephrology, Department of Medicine, Cumming School of Medicine, University of Calgary, AB, Canada
| | | | | | - Adeera Levin
- University of British Columbia and Vancouver General Hospital, Canada
- Division of Nephrology, The University of British Columbia, Vancouver, Canada
- BC Provincial Renal Agency, Vancouver, Canada
| | - Philip McFarlane
- Division of Nephrology, St. Michael’s Hospital, Toronto, ON, Canada
- Division of Nephrology, Department of Medicine, University of Toronto, ON, Canada
| | - Ron Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - Bhanu Prasad
- Division of Nephrology, Department of Medicine, Regina General Hospital, SK, Canada
- College of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Normand Proulx
- CISSS de l’Outaouais, Pavillon de Hull, Gatineau, QC, Canada
- McGill University, Montreal, QC, Canada
| | - Daniel Schwartz
- Division of Nephrology, The University of British Columbia, Vancouver, Canada
| | - Manish Sood
- Ottawa Hospital Research Institute, ON, Canada
- Department of Medicine, The Ottawa Hospital, ON, Canada
| | - Rita Suri
- Department of Medicine, McGill University Health Centre Research Institute, McGill University, Montreal, QC, Canada
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Engler F, Kerschbaum J, Keller F, Mayer G. Prevalence, patient burden and physicians' perception of pruritus in haemodialysis patients. Nephrol Dial Transplant 2024; 39:277-285. [PMID: 37429597 PMCID: PMC10828189 DOI: 10.1093/ndt/gfad152] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Chronic kidney disease-associated pruritus (CKD-aP) is an underrated symptom in patients with impaired kidney function. The present study assessed the prevalence, impact on quality of life (QoL) and risk factors for CKD-aP in a contemporary national cohort of patients on haemodialysis. In addition, we evaluated attending physicians' awareness and approach to therapy. METHODS Validated patient's and physician's questionnaires on pruritus severity and QoL were used in combination with information obtained by the Austrian Dialysis and Transplant Registry. RESULTS The prevalence of mild, moderate and severe pruritus in 962 observed patients was 34.4%, 11.4% and 4.3%. Physicians' estimated prevalence values were 25.0 (95% CI 16.8-33.2), 14.4 (11.3-17.6) and 6.3% (4.9-8.3), respectively. The estimated national prevalence estimate extrapolated from the observed patients was 45.0% (95% CI 39.5-51.2) for any, 13.9% (95% CI 10.6-17.2) for moderate and 4.2% (95% CI 2.1-6.2) for severe CKD-aP. CKD-aP severity was significantly associated with impaired QoL. Risk factors for moderate-severe pruritus were higher C-reactive protein [odds ratio (OR) 1.61 (95% CI 1.07-2.43)] and parathyroid hormone (PTH) values [OR 1.50 (95% CI 1.00-2.27)]. Therapy for CKD-aP included changes in the dialysis regimen, topical treatments, antihistamines, gabapentin and pregabalin and phototherapy in a majority of centres. CONCLUSIONS While the overall prevalence of CKD-aP in our study is similar to that in previously published literature, the prevalence of moderate-severe pruritus is lower. CKD-aP was associated with reduced QoL and elevated markers of inflammation and PTH. The high awareness of CKD-aP in Austrian nephrologists may explain the lower prevalence of more severe pruritus.
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Affiliation(s)
- Franziska Engler
- Department of Internal Medicine IV – Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria
| | - Julia Kerschbaum
- Department of Internal Medicine IV – Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria
- Austrian Dialysis and Transplant Registry, Medical University Innsbruck, Innsbruck, Austria
| | - Felix Keller
- Department of Internal Medicine IV – Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria
| | - Gert Mayer
- Department of Internal Medicine IV – Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria
- Austrian Dialysis and Transplant Registry, Medical University Innsbruck, Innsbruck, Austria
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Yamamoto S, Tanaka T, Omori K, Ei I, Kikuchi K, Konagai A, Goto S, Kitamura N, Narita I. Pruritus and protein-bound uremic toxins in patients undergoing hemodialysis: a cross-sectional study. Clin Kidney J 2024; 17:sfae007. [PMID: 38283986 PMCID: PMC10818225 DOI: 10.1093/ckj/sfae007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Indexed: 01/30/2024] Open
Abstract
Background Patients undergoing hemodialysis frequently experience pruritus; its severity is associated with poor quality of life and mortality. Recent progress in hemodialysis treatment has improved the removal of small- and middle-molecular-weight molecules; however, the removal of protein-bound uremic toxins (PBUTs) remains difficult. It is possible that pruritus is associated with serum PBUTs in patients undergoing hemodialysis. Methods We conducted a multicenter cross-sectional study in patients undergoing hemodialysis (n = 135). The severity of pruritus was assessed using the 5D-itch scale and medication use. Serum PBUTs, including indoxyl sulfate, p-cresyl sulfate, indole acetic acid, phenyl sulfate, and hippuric acid, were measured using mass spectrometry; the PBUT score was calculated from these toxins using principal component analysis. Univariate and multiple regression analyses were performed to examine independent predictors of pruritus. Results Pruritus was reported by 62.2%, 21.5%, and 13.3%, 1.5% and 0.7% as 5 (not at all), 6-10, 11-15, 16-20, and 21-25 points, respectively. The PBUT score was higher in patients undergoing dialysis having pruritus than those without pruritus (0.201 [-0.021 to 0.424] vs -0.120 [-0.326 to 0.087]; P = 0.046). The PBUT score was shown to have an association with the presence of pruritus (coefficient 0.498[Formula: see text]0.225, odds ratio: 1.65 [1.06-2.56]; P = 0.027). Conclusion Uremic pruritus was frequently found and associated with the PBUT score in patients undergoing hemodialysis. Further studies are required to clarify the impact of PBUTs on uremic pruritus and to explore therapeutic strategies in patients undergoing hemodialysis.
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Affiliation(s)
- Suguru Yamamoto
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Takahiro Tanaka
- Clinical and Translational Research Center, Niigata University Medical and Dental Hospital, Niigata, Japan
| | | | - Isei Ei
- Santo-Second Clinic, Niigata, Japan
| | - Kaori Kikuchi
- Research and Development Division, Kureha Corporation, Tokyo, Japan
| | - Ayano Konagai
- Research and Development Division, Kureha Corporation, Tokyo, Japan
| | - Shin Goto
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Nobutaka Kitamura
- Clinical and Translational Research Center, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Shah S, Onugha E, Swartz SJ. Chronic kidney disease-associated pruritus: what is known and its application in children. Pediatr Nephrol 2024; 39:25-35. [PMID: 37171581 DOI: 10.1007/s00467-023-05998-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/04/2023] [Accepted: 04/17/2023] [Indexed: 05/13/2023]
Abstract
Chronic kidney disease-associated pruritus (CKD-aP) or uremic pruritus (UP) is a frequent symptom in patients with kidney failure receiving kidney replacement therapy. Severe chronic kidney disease-associated pruritus correlates with poor outcome in patients on dialysis. It is multifactorial in etiology and has a significant impact on quality of life. There is, however, limited data for children. This review summarizes current epidemiology, clinical characteristics, pruritus scoring systems, and available therapeutic options for pruritus in patients with chronic kidney disease and those receiving dialysis. Optimal care requires proper awareness of the severity of symptoms, the impact on quality of life, and the possible long-term outcomes. Optimizing dialysis prescription and correcting electrolyte abnormalities are important treatment targets. A wide range of therapeutic options is also available although none are well-studied in children. An earlier recognition of this debilitating symptom in children and treatment is imperative. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Shweta Shah
- Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA.
| | - Elizabeth Onugha
- Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Sarah J Swartz
- Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
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Pan M, Wang G, Zhou L, Xu Y, Yao L, Wu C, Mei C, Zhao Z, Sun D, Guan T, Chen Q, Shi M, Xu H, Zeng W, Li F, Yan R, Liu BC. Safety and effectiveness of HSK21542 for hemodialysis patients: a multiple ascending dose study. Front Pharmacol 2023; 14:1203642. [PMID: 37876731 PMCID: PMC10590914 DOI: 10.3389/fphar.2023.1203642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 09/22/2023] [Indexed: 10/26/2023] Open
Abstract
Background: HSK21542, a novel selective peripherally-restricted κ-opioid receptor agonist has been proven to be a safe and effective analgesic and antipruritic drug in both in vitro and in vivo studies. We aimed to evaluate its safety, pharmacokinetics and efficacy in hemodialysis patients over a 1-week treatment period, and to establish the optimal dosage for a further 12-week stage 2 trial. Methods: In this multiple ascending dose study, hemodialysis patients were randomly assigned to receive HSK21542 (0.05-0.80 μg/kg), or a placebo three times within 2.5 h at the end of each dialysis session for 1 week. Safety evaluations included reports of treatment-emergent adverse events (TEAEs); pharmacokinetics and efficacy outcomes were also assessed. Results: Among the 44 screened patients, 41 were enrolled and completed the trial. The overall incidence of TEAEs was higher in the HSK21542 group compared to the placebo group, with an incidence of 75.0%, 50.0%, 75.0%, and 88.9% in the range of 0.05-0.80 μg/kg. All TEAEs were grade 1 or 2 in severity. HSK21542 exhibited linear pharmacokinetics characteristics within the dose range 0.05-0.80 μg/kg, without drug accumulation after multiple-doses. Compared to the placebo, a significant decrease of the weekly mean Worst Itching Intensity Numerical Rating Scale was found in the HSK21542-0.30 μg/kg group (p = 0.046), but without significant improvement in the Skindex-16 score. Conclusion: HSK21542 was well tolerated in the dose range 0.05-0.80 μg/kg in hemodialysis patients. HSK21542-0.3 μg/kg exhibited promising efficacy in patients with moderate to severe pruritus and warrants a further Stage 2 trial. Clinical Trial Registration: https://clinicaltrials.gov/, identifier NCT04470154.
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Affiliation(s)
- Mingming Pan
- Department of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, China
| | - Guihua Wang
- Department of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, China
| | - Li Zhou
- Division of Nephrology, Kidney Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Yan Xu
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Li Yao
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, China
| | - Chaoqing Wu
- Department of Nephrology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Changlin Mei
- Division of Nephrology, The Second Affiliated Hospital Navy Medical University, Shanghai, China
| | - Zhanzheng Zhao
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Dong Sun
- Department of Nephrology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Tianjun Guan
- Division of Nephrology, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Qinkai Chen
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Ming Shi
- Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Hui Xu
- Division of Nephrology, Xiangya Hospital of the Central South University, Changsha, China
| | - Weifang Zeng
- Sichuan Haisco Pharmaceutical Co., Ltd., Chengdu, China
| | - Fangqiong Li
- Sichuan Haisco Pharmaceutical Co., Ltd., Chengdu, China
| | - Rui Yan
- Department of Nephrology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Bi-Cheng Liu
- Department of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, China
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Titapiccolo JI, Lonati C, Goethel-Paal B, Bello AR, Bellocchio F, Pizzo A, Theodose M, Salvador MEB, Schofield M, Cioffi M, Basnayake K, Chisholm C, Mitrovic S, Trkulja M, Arens HJ, Stuard S, Neri L. Chronic kidney disease-associated pruritus (CKD-aP) is associated with worse quality of life and increased healthcare utilization among dialysis patients. Qual Life Res 2023; 32:2939-2950. [PMID: 37269433 DOI: 10.1007/s11136-023-03438-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2023] [Indexed: 06/05/2023]
Abstract
PURPOSE Chronic pruritus significantly impairs hemodialysis patients' health status and quality of life (QOL) and it is associated with higher mortality rate, more frequent hospitalizations, poorer dialysis and medication adherence, and deteriorated mental status. However, pruritus is still underestimated, underdiagnosed, and undertreated in the real-life clinical scenario. We investigated prevalence, clinical characteristics, clinical correlates, severity as well as physical and psychological burden of chronic pruritus among adult hemodialysis patients in a large international real-world cohort. METHODS We conducted a retrospective cross-sectional study of patients registered in 152 Fresenius Medical Care (FMC) NephroCare clinics located in Italy, France, Ireland, United Kingdom, and Spain. Demographic and medical data were retrieved from the EuCliD® (European Clinical) database, while information on pruritus and QoL were abstracted from KDQOL™-36 and 5-D Itch questionnaire scores. RESULTS A total of 6221 patients were included, of which 1238 were from France, 163 Ireland, 1469 Italy, 2633 Spain, and 718 UK. The prevalence of mild-to-severe pruritus was 47.9% (n = 2977 patients). Increased pruritus severity was associated with increased use of antidepressants, antihistamines, and gabapentin. Patients with severe pruritus more likely suffered from diabetes, more frequently missed dialysis sessions, and underwent more hospitalizations due to infections. Both mental and physical QOL scores were progressively lower as the severity of pruritus increased; this association was robust to adjustment for potential confounders. CONCLUSION This international real-world analysis confirms that chronic pruritus is a highly prevalent condition among dialysis patients and highlights its considerable burden on several dimensions of patients' life.
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Affiliation(s)
- Jasmine Ion Titapiccolo
- International Data Science-Clinical Advanced Analytics, Global Medical Office, Fresenius Medical Care, Palazzo Pignano, Italy
| | - Caterina Lonati
- Center for Preclinical Research, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Berit Goethel-Paal
- Global Medical Office, EMEA CoE Clinical & Therapeutical Governance, Fresenius Medical Care, Bad Homburg, Germany
| | | | - Francesco Bellocchio
- International Data Science-Clinical Advanced Analytics, Global Medical Office, Fresenius Medical Care, Palazzo Pignano, Italy
| | | | | | | | | | | | | | - Chis Chisholm
- Fresenius Medical Care (UK) Ltd., 2HU, Sutton-in-Ashfield, UK
| | - Suzanne Mitrovic
- Nursing Care Care Operations EMEA, Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Marjelka Trkulja
- Nursing Care Care Operations EMEA, Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Hans-Juergen Arens
- Frenova International Clinical Research Services, Global Medical Office, Fresenius Medical Care, Bad Homburg, Germany
| | - Stefano Stuard
- Global Medical Office, EMEA CoE Clinical & Therapeutical Governance, Fresenius Medical Care, Bad Homburg, Germany
| | - Luca Neri
- International Data Science-Clinical Advanced Analytics, Global Medical Office, Fresenius Medical Care, Palazzo Pignano, Italy.
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Elsayed MM, Elgohary IE, Abdelhamid HHS, Zaki SA. The effectiveness of sertraline in alleviating uremic pruritus in hemodialysis patients: a randomized clinical trial. BMC Nephrol 2023; 24:155. [PMID: 37270517 DOI: 10.1186/s12882-023-03212-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 05/22/2023] [Indexed: 06/05/2023] Open
Abstract
INTRODUCTION Uremic pruritus (UP) is a common and distressing symptom in end stage renal disease (ESRD) patients. Many approaches have been tested to improve UP without a clear success. We aimed to assess the effect of sertraline on UP in hemodialysis (HD) patients. METHODS This research is a double-blinded, placebo-controlled, multicentric randomized clinical trial which included sixty patients maintained on regular HD. Patients were allocated to receive sertraline 50 mg twice daily or placebo for 8 weeks. The Visual analogue scale (VAS) and the 5-D itch scale were used to assess pruritus before and after the course of treatment. RESULTS At study end in sertraline group, there was a significant decrease from baseline findings in the VAS score (p < 0.001), and the 5-D itch scale (p < 0.001). On the other hand, in placebo group the VAS score showed a slight non-significant decrease (p = 0.469), and the 5-D scale (p = 0.584) increased from baseline measurements. The percentage of patients with severe and very severe pruritus decreased significantly in the sertraline group in both scores [(VAS score: p = 0.004), (5-D itch score: p = 0.002)] with no significant change in the placebo group [(VAS score: p = 0.739), (5-D itch scale: p = 0.763)]. There was a significant positive relation between the VAS and 5-D itch scores and serum urea with p value of 0.002 and 0.001 respectively, and serum ferritin with p value of < 0.001 with both. CONCLUSIONS Patients treated with sertraline had a significant improvement in pruritus as compared with those who received placebo suggesting a potential role for sertraline to treat uremic pruritus in HD patients. Larger randomized clinical trials are needed to confirm these findings. TRIAL REGISTRATION ClinicalTrials.gov NCT05341843. First registration date: 22/04/2022.
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Affiliation(s)
- Mohamed Mamdouh Elsayed
- Nephrology and Internal Medicine Department, Faculty of Medicine, Alexandria University, Alkhartoom Square, El Azareeta, Alexandria, 21131, Egypt.
| | - Iman Ezzat Elgohary
- Nephrology and Internal Medicine Department, Faculty of Medicine, Alexandria University, Alkhartoom Square, El Azareeta, Alexandria, 21131, Egypt
| | | | - Sherif Aziz Zaki
- Nephrology and Internal Medicine Department, Faculty of Medicine, Alexandria University, Alkhartoom Square, El Azareeta, Alexandria, 21131, Egypt
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Efficacy and Safety of Modified Polyethersulfone Hemodialysis Filters in Comparison to Conventional Filters: A Non-inferiority Clinical Trial. Nephrourol Mon 2023. [DOI: 10.5812/numonthly-130299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023] Open
Abstract
Background: The efficacy and quality of hemodialysis (HD) are closely related to the dialyzer characteristics. Objectives: This study aimed to determine the efficacy and complications of modified polyethersulfone (m-PES) -1.5 hollow fiber filters in comparison to conventional filters during HD. Methods: This non-inferiority crossover randomized clinical trial was performed in adult dialysis units at three HD centers within May 2019 to March 2020. The patients were randomly enrolled in two groups. Group A was first put on HD for six sessions with a low or high flux smart flux filter (m-PES-1.5 hollow fiber), which was made in Italy by Medica S.P.A. Group. Group B was hemodialyzed with a corresponding low or high flux filter made in Iran by Meditechsys Company. After a two-week clearance phase, the patients were dialyzed for six sessions with the opposite filter of the first six sessions. Laboratory variables, such as blood urea nitrogen and creatinine, were measured. Kt/V (i.e., a measurement of HD efficacy) and urea reduction ratio (URR) were calculated. Additionally, blood pressure was monitored. Results: A total of 40 patients were entered into the final analysis. No matter which filter was used, no statistically significant differences were observed in URR, creatinine, Kt/V, and blood pressure at different times during dialysis between the two types of filters. Packaging problems (P < 0.001) and blood clotting (P = 0.009) were two more frequent complications in the m-PES group. Conclusions: This study showed that smart flux m-PES-1.5 hollow fiber filters are similar to Meditechsys Company filters.
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Prasad B, Gagarinova M, Sharma A. Five Things to Know About Pruritus in Patients on Dialysis. Can J Kidney Health Dis 2023; 10:20543581221149620. [PMID: 36711226 PMCID: PMC9880569 DOI: 10.1177/20543581221149620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 11/30/2022] [Indexed: 01/26/2023] Open
Affiliation(s)
- Bhanu Prasad
- Division of Nephrology, Department of
Medicine, Regina General Hospital, SK, Canada
| | | | - Aditi Sharma
- Dr. T Bhanu Prasad Medical Prof Corp,
Regina, SK, Canada
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11
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Ko MJ, Peng YS, Wu HY. Uremic pruritus: pathophysiology, clinical presentation, and treatments. Kidney Res Clin Pract 2023; 42:39-52. [PMID: 35545226 PMCID: PMC9902728 DOI: 10.23876/j.krcp.21.189] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 12/25/2021] [Indexed: 11/04/2022] Open
Abstract
Uremic pruritus is one of the most common and bothersome symptoms in patients with end-stage renal disease. Most patients with uremic pruritus experience a prolonged and relapsing course and significant impairments of quality of life. The pathophysiology of uremic pruritus is not completely understood. A complex interplay among cutaneous biology and the nervous and immune systems has been implicated, with the involvement of various inflammatory mediators, neurotransmitters, and opioids. Uremic pruritus treatment outcomes are often unsatisfactory. Clinical trials have mostly been small in scale and have reported inconsistent results. Recent evidence shows that gabapentinoids, nalfurafine, and difelikefalin are effective for relieving uremic pruritus in hemodialysis patients. This review provides an overview of the epidemiology and proposed mechanisms of uremic pruritus, then highlights the manifestations of and clinical approach to uremic pruritus. Current evidence regarding treatment options, including topical treatments, treatment of underlying disease, phototherapy, and systemic treatments, is also outlined. With a better understanding of uremic pruritus, more therapeutic options can be expected in the near future.
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Affiliation(s)
- Mei-Ju Ko
- Department of Dermatology, Taipei City Hospital, Taipei City, Taiwan,Department of Dermatology, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
| | - Yu-Sen Peng
- Division of Nephrology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan,Department of Applied Cosmetology, Lee-Ming Institute of Technology, New Taipei City, Taiwan,Department of Healthcare Administration, Asia Eastern University of Science and Technology, New Taipei City, Taiwan
| | - Hon-Yen Wu
- Division of Nephrology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan,School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan,Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei City, Taiwan,Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan,Correspondence: Hon-Yen Wu Division of Nephrology, Department of Internal Medicine, Far Eastern Memorial Hospital, No. 21, Sec. 2, Nanya S. Rd., Banciao Dist., New Taipei City 220, Taiwan. E-mail:
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12
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Molina P, Ojeda R, Blanco A, Alcalde G, Prieto-Velasco M, Aresté N, Buades JM, Simó VE, Goicoechea M, Pérez-Morales RE, Sánchez-Álvarez E, Sánchez-Villanueva R, Montesa M, Arenas MD. Etiopathogenesis of chronic kidney disease-associated pruritus: putting the pieces of the puzzle together. Nefrologia 2023; 43:48-62. [PMID: 37173258 DOI: 10.1016/j.nefroe.2023.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 06/28/2022] [Indexed: 05/15/2023] Open
Abstract
Defined as the unpleasant sensation that causes the desire to scratch, pruritus is the most common skin symptom associated with uremia and appears in almost half of patients with advanced chronic kidney disease (CKD). Beyond its direct impact on quality of life, CKD-associated pruritus (CKD-aP) is an independent predictor of mortality that also has a synergistic effect with other quality of life-related symptoms, such as insomnia, depression, and anxiety. Although different mechanisms have been proposed to explain the origin of Pa-ERC, its etiopathogenesis is still not fully understood. Since new therapeutic targets have been identified and several clinical trials have recently shown promising results, our current understanding of the interrelationships has expanded significantly and the pathophysiological mechanisms underlying CKD-aP are now considered to be multifactorial. The potential triggers of pruritus in patients with CKD are discussed in this review, including hypotheses about skin xerosis, accumulation of uremic toxins, dysregulation of the immune system and systemic inflammation, uremic neuropathy, and imbalances in the endogenous opioid system. Other non-uremic causes of pruritus are also discussed, with the aim of guiding the physicians to apply an adequate aetiopathogenic approach to CKD-aP in their day-to-day clinical practice.
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Affiliation(s)
- Pablo Molina
- Servicio de Nefrología, FISABIO, Hospital Universitari Dr Peset, Departamento de Medicina, Universitat de València, Valencia, Spain.
| | - Raquel Ojeda
- Servicio de Nefrología, Hospital Universitario Renia Sofía, Córdoba, Spain
| | - Ana Blanco
- Fresenius Medical Care, Centro de Diálisis Alcobendas, Madrid, Spain; Servicio de Nefrología, Hospital Quirón Ruber Juan Bravo, Madrid, Spain
| | - Guillermo Alcalde
- Servicio de Nefrología, BIOARABA, Hospital Universitario Araba, Osakidetza, Universidad del País Vasco, Vitoria-Gasteiz, Álava, Spain
| | | | - Nuria Aresté
- Servicio de Nefrología, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Juan Manuel Buades
- Servicio de Nefrología, Hospital Universitario Son Llàtzer, Institut d'Investigació Sanitària de les Illes Balears (IdISBa), Palma, Spain
| | - Vicent Esteve Simó
- Servicio de Nefrologia, Hospital Terrassa, Consorci Sanitari Terrassa (CST), Terrassa, Barcelona, Spain
| | - Marian Goicoechea
- Servicio de Nefrología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Rosa Elena Pérez-Morales
- Servicio de Nefrología. Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Emilio Sánchez-Álvarez
- Servicio de Nefrología, Hospital Universitario de Cabueñes, Red de Investigación Renal (REDINREN), Gijón, Asturias, Spain
| | | | - María Montesa
- Servicio de Nefrología, FISABIO, Hospital Universitari Dr Peset, Departamento de Medicina, Universitat de València, Valencia, Spain
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13
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Analysis of Nursing Effect of Comprehensive Nursing Intervention on Hemodialysis Patients with Uremia. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:5820707. [PMID: 36237577 PMCID: PMC9529519 DOI: 10.1155/2022/5820707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/08/2022] [Accepted: 08/22/2022] [Indexed: 01/26/2023]
Abstract
Uremic pruritus affects 50-90% of hemodialysis patients, making it one of the most frequent medical issues among this group. Pruritus can lead to skin infections, desquamation, pathological skin changes, sleep problems, anxiety, depression, and social problems. The epidemic of uremia pneumonia has put a lot of stress on hemodialysis patients, resulting in negative feelings. As a result, during the prevention and control of uremia, rigorous management and improved nursing intervention are critical. During the uremia disease outbreak, this study will examine and assess the impact of clinically refined nurse intervention on patients receiving maintenance hemodialysis.
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14
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Etiopatogenia del prurito asociado a la enfermedad renal crónica: recomponiendo las piezas del puzle. Nefrologia 2022. [DOI: 10.1016/j.nefro.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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15
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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: 4] [Impact Index Per Article: 2.0] [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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16
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Schricker S, Kimmel M. Unravelling the pathophysiology of chronic kidney disease-associated pruritus. Clin Kidney J 2022; 14:i23-i31. [PMID: 34987780 PMCID: PMC8702819 DOI: 10.1093/ckj/sfab200] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Indexed: 12/12/2022] Open
Abstract
For decades, itch related to chronic kidney disease (CKDaP) has been a clinical problem, but the aetiology and pathophysiology of CKDaP are still not yet fully understood—currently the underlying pathophysiological mechanisms are thought to be multifactorial. As new therapeutic targets have recently been identified and clinical trials have shown promising results, our current understanding of the interrelationships has expanded significantly. Here we review the pathophysiology and recent findings on modulation and sensitization of itch contributing to the development of CKDaP, covering hypothesis regarding immune system dysfunction, metabolic changes, uremic toxin deposition, peripheral neuropathy and imbalances in the endogenous opioid system.
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Affiliation(s)
- Severin Schricker
- Department of General Internal Medicine and Nephrology, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Martin Kimmel
- Department of Internal Medicine, Division of Nephrology, Hypertension and Autoimmune Disorders, Alb-Fils Kliniken, Göppingen, Germany
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17
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Ahdoot RS, Kalantar-Zadeh K, Burton JO, Lockwood MB. Novel approach to unpleasant symptom clusters surrounding pruritus in patients with chronic kidney disease and on dialysis therapy. Curr Opin Nephrol Hypertens 2022; 31:63-71. [PMID: 34750335 PMCID: PMC8633148 DOI: 10.1097/mnh.0000000000000752] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW Chronic kidney disease-associated-pruritus (CKD-aP) is a common symptom in patients with end-stage kidney disease (ESKD) undergoing dialysis. CKD-aP typically occurs alongside other debilitating symptoms and may comprise so-called 'symptom clusters' which have synergistic effects that adversely impact patient health-related quality of life (HRQoL). Importantly, symptoms in a cluster may share a common biological mechanism. Here we review the clinical impact of CKD-aP and its association with other symptoms reported by dialysis patients. The clinical benefits of treating pruritus and its potential impact on other symptoms are also addressed. RECENT FINDINGS Studies have shown CKD-aP significantly impairs HRQoL in patients with ESKD undergoing dialysis and is associated with adverse clinical outcomes, including increased risk of infections, hospitalizations, and mortality. Despite these negative effects, CKD-aP remains underrecognized and undertreated in clinical practice. CKD-aP is frequently associated with other symptoms, including disturbed sleep/poor sleep quality, anxiety, depression, and pain. Clinical studies of antipruritic therapies show that reduction of itch intensity may also alleviate other associated symptoms, such as poor sleep quality. SUMMARY CKD-aP and its associated symptoms are inadequately managed in clinical practice. Greater understanding and awareness of CKD-aP and its surrounding symptom clusters in dialysis patients may improve their overall symptom management and HRQoL.
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Affiliation(s)
- Rebecca S. Ahdoot
- Department of Medicine, Division of Nephrology Hypertension and Kidney Transplantation, University of California Irvine (UCI), Orange
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California, Irvine, California, USA
| | - James O. Burton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Mark B. Lockwood
- Department of Biobehavioral Nursing Science, University of Illinois at Chicago, College of Nursing, Chicago, Illinois, USA
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18
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Lipman ZM, Paramasivam V, Yosipovitch G, Germain MJ. Clinical management of chronic kidney disease-associated pruritus: current treatment options and future approaches. Clin Kidney J 2021; 14:i16-i22. [PMID: 34987779 PMCID: PMC8702820 DOI: 10.1093/ckj/sfab167] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Indexed: 12/13/2022] Open
Abstract
Chronic kidney disease (CKD)-associated pruritus (CKD-aP) is an underdiagnosed yet severely distressing condition that impacts 60% of patients on dialysis and many nondialysis patients with Stages 3–5 CKD. However, despite its high prevalence, there are currently limited treatment options available for these patients and a lack of treatment guidelines for clinicians. In this manuscript, we reviewed the available literature in order to evaluate the current management and treatment options for CKD-aP, including dialysis management, topical treatments, gabapentinoids, opioids and alternative medicine. We also review the available data on CKD-aP treatments in development and propose new guidelines for managing patients with CKD-aP.
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Affiliation(s)
- Zoe M Lipman
- Dr Phillip Frost Department of Dermatology and Miami Itch Center, University of Miami, Miami, FL, USA
| | - Vijayakumar Paramasivam
- Division of Nephrology, Renal Transplant Associates of New England, Baystate Medical Center U Mass Medical School, Springfield, MA, USA
| | - Gil Yosipovitch
- Dr Phillip Frost Department of Dermatology and Miami Itch Center, University of Miami, Miami, FL, USA
| | - Michael J Germain
- Division of Nephrology, Renal Transplant Associates of New England, Baystate Medical Center U Mass Medical School, Springfield, MA, USA
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19
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Kim D, Pollock C. Epidemiology and burden of chronic kidney disease-associated pruritus. Clin Kidney J 2021; 14:i1-i7. [PMID: 34987777 PMCID: PMC8702817 DOI: 10.1093/ckj/sfab142] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 07/30/2021] [Indexed: 01/12/2023] Open
Abstract
Chronic kidney disease–associated pruritus (CKD-aP) is a common, yet underrecognized condition in patients with CKD and end-stage kidney disease (ESKD). Real-world observational studies indicate that CKD-aP affects up to 80% of ESKD patients undergoing haemodialysis (HD), with ∼40% experiencing moderate to severe itch. CKD-aP can negatively impact patients’ mental and physical health-related quality of life (HRQoL) and is also associated with sleep disturbance and depression. Several studies have found that CKD-aP is a predictor of adverse medical outcomes, including an increased risk of hospitalizations and mortality. In this article we review the literature relating to the epidemiology of CKD-aP to describe its prevalence across the treatment spectrum of CKD (non-dialysis, HD, peritoneal dialysis and transplant recipients) and to summarize potential risk factors associated with its development. We also review key data from studies that have evaluated the impact of CKD-aP on HRQoL and medical outcomes.
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Affiliation(s)
- Dana Kim
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Carol Pollock
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
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20
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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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21
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Lu PH, Tai YC, Yu MC, Lin IH, Kuo KL. Western and complementary alternative medicine treatment of uremic pruritus: A literature review. Tzu Chi Med J 2021; 33:350-358. [PMID: 34760630 PMCID: PMC8532575 DOI: 10.4103/tcmj.tcmj_151_20] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/10/2020] [Accepted: 09/18/2020] [Indexed: 12/28/2022] Open
Abstract
Uremic pruritus (UP), also called chronic kidney disease-associated pruritus (CKD-aP), is a bothersome symptom that causes sleep disturbance, anxiety, depression, and reduced quality of life. Pruritus often occurs in patients with end-stage renal disease. There is still no definite treatment for UP due to its unclear pathogenesis. We searched electronic databases (PubMed and Google Scholar) and gathered the latest clinical trials and pilot studies of Western and complementary alternative medicine (CAM) therapies for UP in English. These UP studies were separated into three main groups: systemic, topical, and others and CAM. Gabapentin, nalfurafine, acupuncture, and Chinese herbal bath therapy (CHBT) show antipruritic effects, with higher evidence grades in the meta-analysis. Emollients with additive compounds are more effective for reducing itch than emollients without additives. Supplements for deficient elements, such as zinc, omega-3, and omega-6, also show benefits for pruritus improvement. CAM therapies such as acupuncture, herbs, and herbal baths or creams all have good results for UP treatment. We summarize the treatments and suggest a treatment algorithm for UP according to severity. Some UP therapies are already supported by large-scale clinical evidence, and some new treatments can provide patients with new hope and treatment options. However, these new methods still need large population studies and further exploration.
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Affiliation(s)
- Ping-Hsun Lu
- Department of Chinese Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan.,School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Hualien, Taiwan
| | - Yu-Chih Tai
- Department of Chinese Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Min-Chien Yu
- Department of Chinese Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - I-Hsin Lin
- School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Hualien, Taiwan
| | - Ko-Lin Kuo
- Division of Nephrology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
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22
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Chronic Kidney Disease-Associated Pruritus. Toxins (Basel) 2021; 13:toxins13080527. [PMID: 34437400 PMCID: PMC8402524 DOI: 10.3390/toxins13080527] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/12/2021] [Accepted: 07/19/2021] [Indexed: 12/26/2022] Open
Abstract
Pruritus is a distressing condition associated with end-stage renal disease (ESRD), advanced chronic kidney disease (CKD), as well as maintenance dialysis and adversely affects the quality of life (QOL) of these patients. It has been reported to range from 20% to as high as 90%. The mechanism of CKD-associated pruritus (CKD-aP) has not been clearly identified, and many theories have been proposed to explain it. Many risk factors have been found to be associated with CKD-aP. The pruritus in CKD presents with diverse clinical features, and there are no set features to diagnose it.The patients with CKD-aP are mainly treated by nephrologists, primary care doctors, and dermatologists. Many treatments have been tried but nothing has been effective. The search of literature included peer-reviewed articles, including clinical trials and scientific reviews. Literature was identified through March 2021, and references of respective articles and only articles published in the English language were included.
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23
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Koyuncu S, Solak EO, Karakukcu C, Gundogdu A, Uysal C, Zararsız G, Kocyigit I, Sipahioğlu MH, Oymak O, Borlu M, Tokgoz B. Evaluation of the causes affecting the development of pruritus in patients with peritoneal dialysis. Int Urol Nephrol 2021; 54:619-625. [PMID: 34213714 DOI: 10.1007/s11255-021-02929-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 06/15/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Several factors play a role in the pathogenesis of pruritus in uremic patients. The pathophysiology is complex and many factors have been identified in these patients. The aim of this study was to investigate the presence, severity, and possible causes of pruritus in patients with peritoneal dialysis (PD) . METHODS Eighty patients, who received continuous ambulatory peritoneal dialysis (CAPD) treatment, were included in this study. Biochemical measurements, parathormone, C-reactive protein (CRP), and vitamin B12 levels of all the patients were recorded. Furthermore, substance P (SP) levels were measured by ELISA methods. Patients were examined by a dermatologist and pruritus degrees were queried using the visual analog score (VAS) with skin dryness. RESULTS In generalized linear model analysis, total urea clearance and SP independently predicted VAS scores. SP was significantly predictive in ROC analysis in identifying the VAS score in patients with peritoneal dialysis. The sensitivity and specificity of SP were 80% and 67% (cut-off > 364), respectively, with an area under the ROC curve of 0.757 (95% CI 0.650-0.865, p < 0.001). SP also was significantly predictive in ROC analysis in identifying xerosis in PD patients. CONCLUSION Pruritus was proportional to the amount of substance P and total urea clearance was another reason affecting pruritus in peritoneal dialysis patients.
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Affiliation(s)
- Sumeyra Koyuncu
- Department of Nephrology, Erciyes Medical Faculty, Kayseri, Turkey.
| | - Eda Oksum Solak
- Department of Dermatology, Erciyes Medical Faculty, Kayseri, Turkey
| | - Cigdem Karakukcu
- Departments of Biochemistry, Kayseri Education and Research Hospital, Kayseri, Turkey
| | - Ali Gundogdu
- Department of Nephrology, Erciyes Medical Faculty, Kayseri, Turkey
| | - Cihan Uysal
- Department of Nephrology, Erciyes Medical Faculty, Kayseri, Turkey
| | - Gökmen Zararsız
- Department of Nephrology, Erciyes Medical Faculty, Kayseri, Turkey
- Department of Dermatology, Erciyes Medical Faculty, Kayseri, Turkey
- Departments of Biochemistry, Kayseri Education and Research Hospital, Kayseri, Turkey
| | - Ismail Kocyigit
- Department of Nephrology, Erciyes Medical Faculty, Kayseri, Turkey
| | | | - Oktay Oymak
- Department of Nephrology, Erciyes Medical Faculty, Kayseri, Turkey
| | - Murat Borlu
- Department of Dermatology, Erciyes Medical Faculty, Kayseri, Turkey
| | - Bulent Tokgoz
- Department of Nephrology, Erciyes Medical Faculty, Kayseri, Turkey
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24
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Chronic Kidney Disease-Associated Itch (CKD-aI) in Children-A Narrative Review. Toxins (Basel) 2021; 13:toxins13070450. [PMID: 34209560 PMCID: PMC8309841 DOI: 10.3390/toxins13070450] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 06/26/2021] [Accepted: 06/28/2021] [Indexed: 01/08/2023] Open
Abstract
Chronic kidney disease (CKD) is a condition of widespread epidemiology and serious consequences affecting all organs of the organism and associated with significant mortality. The knowledge on CKD is rapidly evolving, especially concerning adults. Recently, more data is also appearing regarding CKD in children. Chronic itch (CI) is a common symptom appearing due to various underlying dermatological and systemic conditions. CI may also appear in association with CKD and is termed chronic kidney disease-associated itch (CKD-aI). CKD-aI is relatively well-described in the literature concerning adults, yet it also affects children. Unfortunately, the data on paediatric CKD-aI is particularly scarce. This narrative review aims to describe various aspects of CKD-aI with an emphasis on children, based on the available data in this population and the data extrapolated from adults. Its pathogenesis is described in details, focusing on the growing role of uraemic toxins (UTs), as well as immune dysfunction, altered opioid transmission, infectious agents, xerosis, neuropathy and dialysis-associated aspects. Moreover, epidemiological and clinical aspects are reviewed based on the few data on CKD-aI in children, whereas treatment recommendations are proposed as well, based on the literature on CKD-aI in adults and own experience in managing CI in children.
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25
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Shawky SM, Hamid RAAA, Khedr LE. The correlation between uremic pruritus and blood lead levels in prevalent hemodialysis patients and its relation to the severity of pruritus using visual analog score. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2021. [DOI: 10.1186/s43162-021-00045-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Pruritus is a common and often distressing symptom in patients with chronic kidney disease. Though the pathogenesis of uremic pruritus remains poorly understood, systemic inflammation has presented itself as one of the possible explanations. High blood lead levels (BLLs) have been noted to be associated with inflammation and poor nutritional status in hemodialysis patients. Our aim is to study the relation between blood lead levels and uremic pruritus. This is a cross-sectional study that enrolled 50 patients; all were on regular hemodialysis 3 times per week for at least 6 months. Patients were divided into 2 groups, group 1 (n =10) with no pruritus and group 2 (n=40) with varying degrees of pruritus. Group 2 was further divided according to intensity of pruritus by visual analog score (VAS) into mild (n=10), moderate (n=20), and severe pruritus (n=10).
Results
There was a significant difference in serum lead levels and ferritin levels between groups 1 and 2 (p value < 0.01 and < 0.05, respectively). There was a statistically significant difference in serum lead levels in the groups with varying intensity of pruritus, having higher serum lead levels in patients who exhibited severe pruritus (p value < 0.005) Moreover, a statistically significant relation between elevated blood lead levels and the duration of dialysis was observed in this study.
Conclusion
Uremic pruritus is a multi-factorial phenomenon, and our study showed that blood lead levels in hemodialysis patients might be associated with increased intensity of pruritus.
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Santos-Alonso C, Maldonado Martín M, Sánchez Villanueva R, Álvarez García L, Vaca Gallardo MA, Bajo Rubio MA, Del Peso Gilsanz G, Ossorio González M, Selgas Gutiérrez R. Pruritus in dialysis patients. Review and new perspectives. Nefrologia 2021; 42:S0211-6995(21)00032-1. [PMID: 33707097 DOI: 10.1016/j.nefro.2020.12.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/29/2020] [Accepted: 12/02/2020] [Indexed: 11/24/2022] Open
Abstract
Uremic pruritus (UP) is one of the most uncomfortable symptoms for patients in dialysis. UP has a great impact on dialysis patients' quality of life and has a great prevalence between those (28-70%). Physiopathology of UP is unknown and usually is unnoticed for most nephrologists (in more than 65% of centers is underdiagnosed). This lack of awareness drives to the unsuccessful treatment of this symptom. Moreover, the fact that most studies have been carried out on small populations and the difficulty assessing UP complicates a correct therapeutical approach. For this reason, we have designed treatment algorithms based on the efficacy of the drugs but also its safeness to avoid adverse effects.
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Martin CE, Clotet-Freixas S, Farragher JF, Hundemer GL. Have We Just Scratched the Surface? A Narrative Review of Uremic Pruritus in 2020. Can J Kidney Health Dis 2020; 7:2054358120954024. [PMID: 33117546 PMCID: PMC7573751 DOI: 10.1177/2054358120954024] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 05/04/2020] [Indexed: 01/02/2023] Open
Abstract
Purpose of review: Uremic pruritus is a highly prevalent and debilitating symptom in patients with chronic kidney disease (CKD) and end-stage kidney disease (ESKD). The purpose of this review is to examine current evidence on the mechanisms and treatments of pruritus in CKD and highlight promising areas for future research. Sources of information: Published literature, including randomized controlled trials, cohort studies, case reports, and review articles, was searched for evidence pertaining to the pathophysiology and treatment of uremic pruritus. Methods: A comprehensive narrative review was conducted to explore the molecular mechanisms underlying uremic pruritus, as well as the evidence (or lack thereof) supporting pharmacological and nonpharmacological treatments for uremic pruritus. The potential role of patient sex in the pathophysiology and management of uremic pruritus is also discussed. Key findings: The pathophysiology of uremic pruritus involves a complex interplay of uremic toxins, systemic inflammation, mast cell activation, and imbalance of opioid receptors. Classic treatment strategies for uremic pruritus include optimization of dialysis parameters, amelioration of CKD-related mineral and bone disease, topical emollients and analgesics, antihistamines, the anticonvulsant medications gabapentin and pregabalin, and ultraviolet light B (UV-B) phototherapy. Strong data to support many of these classical treatments for uremic pruritus are limited. Newly evolving treatment approaches for uremic pruritus include opioid receptor modulators, neurokinin-1 inhibitors, and cannabinoids. Further studies regarding their efficacy, pharmacodynamics, and safety in the CKD and ESKD population are needed before these agents are accepted into widespread use. Additional nonpharmacological strategies aimed at treating uremic pruritus include psychotherapy, acupuncture, omega-3 fatty acids, and exercise. Finally, sex differences may exist regarding uremic pruritus, but studies directly addressing sex-specific mechanisms of uremic pruritus remain absent. Limitations: High-quality evidence in the management of uremic pruritus remains lacking. Most recommendations are based on expert opinion or studies involving small numbers of patients. In addition, our understanding of the pathophysiological mechanisms behind uremic pruritus is incomplete and continues to evolve over time. Implications: Uremic pruritus is a common symptom which reduces quality of life in CKD and ESKD. The identification of novel targeted treatment approaches may ease the burden of uremic pruritus in the future.
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Affiliation(s)
- Claire E Martin
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
| | - Sergi Clotet-Freixas
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Janine F Farragher
- Department of Community Health Sciences, University of Calgary, AB, Canada
| | - Gregory L Hundemer
- Division of Nephrology, The Ottawa Hospital and University of Ottawa, ON, Canada
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Karjalian F, Momennasab M, Yoosefinejad AK, Jahromi SE. The Effect of Acupressure on the Severity of Pruritus and Laboratory Parameters in Patients Undergoing Hemodialysis: A Randomized Clinical Trial. J Acupunct Meridian Stud 2020; 13:117-123. [DOI: 10.1016/j.jams.2020.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 05/17/2020] [Accepted: 05/18/2020] [Indexed: 11/29/2022] Open
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Sarhan II, Ibrahim MAH, Kamel NM, Teama NM. Association of high sensitive C reactive protein and dialysis adequacy with uremic pruritus in hemodialysis patients. ALEXANDRIA JOURNAL OF MEDICINE 2020. [DOI: 10.1080/20905068.2020.1786620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- Iman I. Sarhan
- Department of Internal Medicine and Nephrology, Faculty of medicine-Ain Shams University, Cairo, Egypt
| | - Mona Abdel-Halim Ibrahim
- Department of Dermatology, Venerology and Andrology, Faculty of medicine-Ain Shams University, Cairo, Egypt
| | | | - Nahla M. Teama
- Department of Internal Medicine and Nephrology, Faculty of medicine-Ain Shams University, Cairo, Egypt
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Verduzco HA, Shirazian S. CKD-Associated Pruritus: New Insights Into Diagnosis, Pathogenesis, and Management. Kidney Int Rep 2020; 5:1387-1402. [PMID: 32954065 PMCID: PMC7486142 DOI: 10.1016/j.ekir.2020.04.027] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/25/2020] [Accepted: 04/27/2020] [Indexed: 11/19/2022] Open
Abstract
Chronic kidney disease–associated pruritus (CKD-aP) is a common, troubling and in some cases debilitating problem for patients with CKD and end-stage renal disease. Despite a prevalence rate of approximately 20% in CKD and 40% in end-stage renal disease, and a clear association with poorer psychosocial and medical outcomes, this condition is often underreported by patients and overlooked by health care providers. This is likely due, in part, to uncertainty regarding its pathogenesis and treatment. Most commonly, CKD-aP is attributed to toxin build-up, peripheral neuropathy, immune system dysregulation, or opioid dysregulation. Prior treatment studies of CKD-aP have targeted these potential etiologies but have been limited by noncontrolled design, small sample size, and non-uniform definitions of CKD-aP. Recently, several large, randomized controlled trials targeting opioid dysregulation have yielded promising results. These trials have spurred new hope for understanding and treating this condition.
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Affiliation(s)
- Hector Alvarado Verduzco
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Shayan Shirazian
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
- Correspondence: Shayan Shirazian, Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, 622 West 168th Street, PH4-124, New York, New York, USA.
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Kushnir V, Dmytrenko S, Katilov O, Kushnir N. Itching as the onset of pain (part 2). PAIN MEDICINE 2020. [DOI: 10.31636/pmjua.v5i1.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Itching of the skin is a particularly unpleasant subjective sensation that causes the need to scratch. Physiological itching occurs in response to environmental irritants (friction, insect crawling, temperature changes, etc.) and disappears after elimination of the cause. Pathological itching is caused by changes in the skin or throughout the body and causes a strong need to get rid of itching by combing or any other method. Itching is a common symptom of local (dermatological) or general (systemic) disease. It can be limited (localized) or diffuse (generalized).One of the causes of itching is often noted endocrine diseases and metabolic disorders: hyper- and hypofunction of the thyroid gland, diabetes mellitus and hyperparathyroidism. In thyroid hyperfunction, generalized (inconstant and little-pronounced) itching of the skin is observed in the clinical picture only in 10 % of patients. It is accepted that itching of the skin in thyrotoxicosis syndrome is due to increased activity of kinin in combination with an increase in major metabolism and an increase in body and skin temperature (123).Itching caused by impaired bile secretion is characteristic of many diseases of the liver: primary biliary cirrhosis, sclerosing cholangitis, viral hepatitis caused by cholestasis medications and other causes of obstructive jaundice. It is in these cases that prurigo is usually generalized, but in some typical cases it is more pronounced on the feet and palms. With this pathology, itching is caused by obstruction of the biliary tract, however, and to this day, no close correlation has been found between serum bilirubin and the severity of itching.If it was previously thought that itching in pathology of the peripheral or central nervous system, such as multiple sclerosis, neuropathy, compression or irritation of nerves (e.g., paraesthetic dorsalgia, brachioradial itching) is also a significant symptom, then modern studies prove that in more cases, itching is not characteristic of most pathologies of the nervous system, so after a detailed anamnesis, examination and initial research, the patient should be referred to a related specialist, except in cases of about obvious postherpetic neuropathy, painless paresthesia, or brachioradial itching, which can often be guided in the provision of primary care.Instead, there are some psychological conditions and a number of psychiatric illnesses (obsessive-compulsive disorders, depression, and parasite illusions) that are most commonly diagnosed with the exclusion method. Neurotic squabbles are scattered on the body of the excorii, covered with scales that may occur in any area of the body that the patient may reach, but are often limited by limbs.
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Ragazzo J, Cesta A, Jassal SV, Chiang N, Battistella M. Development and Validation of a Uremic Pruritus Treatment Algorithm and Patient Information Toolkit in Patients With Chronic Kidney Disease and End Stage Kidney Disease. J Pain Symptom Manage 2020; 59:279-292.e5. [PMID: 31610269 DOI: 10.1016/j.jpainsymman.2019.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 09/30/2019] [Accepted: 10/01/2019] [Indexed: 01/04/2023]
Abstract
CONTEXT Uremic pruritus (UP) affects up to half of all patients with kidney disease and has been independently associated with poor patient outcomes. UP is a challenging symptom for clinicians to manage as there are no validated guidelines for its treatment. OBJECTIVES The study aimed to develop and validate an algorithm and patient information toolkit for the treatment of UP in patients with kidney disease. METHODS The study involved a literature search and development of an initial draft algorithm, followed by content and face validation of this algorithm. Validation entailed three rounds of interviews with six nephrology clinicians per round. Participants assessed the relevance of each component of the algorithm and then rated a series of statements on a scale of 1-5 to assess face validity of the algorithm. After each round, the content validity index (CVI) of each algorithm component was calculated, and the algorithm was revised by the study team in response to findings. This process was followed by a second study that developed and validated a patient information pamphlet and video. RESULTS Algorithm validation participants were affiliated with three institutions and included seven physicians, four registered nurses, three nurse practitioners, three pharmacists, and a dietician. The average CVI of the algorithm components across all three rounds was 0.89, with 0.80 commonly cited as the lower acceptable limit for content validation. More than 78% of participants rated each face validity statement as "Agree" or "Strongly Agree". For the patient information tools, five clinicians and 15 patients were included in validation. The average CVI was 1.00 for both tools, and the average face validity was 92%. CONCLUSION A treatment algorithm and patient information toolkit for managing UP in patients with kidney disease were developed and validated through expert review. Further research will be conducted on implementation of the treatment algorithm and evaluating patient-reported outcomes.
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Affiliation(s)
- Jessica Ragazzo
- University Health Network, Toronto, Canada; University of Toronto, Toronto, Canada
| | | | - S Vanita Jassal
- University Health Network, Toronto, Canada; University of Toronto, Toronto, Canada
| | | | - Marisa Battistella
- University Health Network, Toronto, Canada; University of Toronto, Toronto, Canada.
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Rehman IU, Chan KG, Munib S, Lee LH, Khan TM. The association between CKD-associated pruritus and quality of life in patients undergoing hemodialysis in Pakistan: A STROBE complaint cross-sectional study. Medicine (Baltimore) 2019; 98:e16812. [PMID: 31490367 PMCID: PMC6739024 DOI: 10.1097/md.0000000000016812] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Chronic kidney disease (CKD)-associated pruritus is one of the most common symptoms found in patients who undergo dialysis for CKD, leading to a compromised quality of life. This study aimed to investigate the association between CKD-associated pruritus and the quality of life in patients undergoing hemodialysis in Pakistan.A cross-sectional multicenter study was carried out from July 2016 to April 2017 in 2 tertiary care hospitals in Pakistan. Patients aged 18 years and above of both genders, undergoing hemodialysis, understood the Urdu language, and were willing to participate; were included.Of 354 recruited patients with a response rate of 100%, majority (66.1%) of the patients were males. The median (intra-quartile range [IQR]) age of patients was 42.0 [34.0-50.0] years. The prevalence of pruritus was 74%. The median [IQR] score for pruritus was 10.0 (out of possible 25) [8.0-12.0]. Multivariate linear regression revealed a statistically significant association between CKD-associated pruritus with age of patients (β = 0.031; 95% confidence interval [CI] = 0.002-0.061; P = .038), duration of CKD (β = -0.013; 95% CI = -0.023 --0.003; P = .014) and quality of life (β= -0.949; 95% CI = -1.450; -0.449). The median [IQR] score for health-related quality of life was 52.00 [43.00-58.00].Prevalence of CKD-associated pruritus was reported to be 74% and it negatively affected the patient's quality of life. Patients with moderate to severe CKD-associated pruritus have poor quality of life. With an increase in intensity of pruritus, the QOL score decreased among the patients undergoing hemodialysis.
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Affiliation(s)
- Inayat Ur Rehman
- School of Pharmacy, Monash University, 47500 Bandar Sunway, Selangor Darul Ehsan, Malaysia
- Department of Pharmacy, Abdul Wali Khan University Mardan Pakistan
| | - Kok Gan Chan
- International Genome Centre, Jiangsu University, Zhenjiang, China
- ISB (Genetics), Faculty of Science, University of Malaya, Kuala Lumpur, Malaysia
| | - Syed Munib
- Department of Nephrology, Institute of Kidney Diseases Peshawar Pakistan
| | - Learn Han Lee
- Novel Bacteria and Drug Discovery (NBDD) Research Group, Microbiome and Bioresource Research Strength, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, 47500 Bandar Sunway, Selangor Darul Ehsan, Malaysia
| | - Tahir Mehmood Khan
- School of Pharmacy, Monash University, 47500 Bandar Sunway, Selangor Darul Ehsan, Malaysia
- The Institute of Pharmaceutical Sciences (IPS), University of Veterinary & Animal Sciences (UVAS), Outfall road, Lahore, Pakistan
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Rehman IU, Lai PS, Kun LS, Lee LH, Chan KG, Khan TM. Chronic Kidney Disease-Associated Pruritus and Quality of Life in Malaysian Patients Undergoing Hemodialysis. Ther Apher Dial 2019; 24:17-25. [PMID: 31152625 DOI: 10.1111/1744-9987.12862] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/01/2019] [Accepted: 05/30/2019] [Indexed: 11/30/2022]
Abstract
CKD-associated pruritus is one of the common symptoms in patients undergoing dialysis, thus contributing to the diminished and compromised quality of life. This study aimed to explore the association between the CKD-associated pruritus on quality of life of patients undergoing hemodialysis in Malaysia. A cross-sectional multicenter study, carried out from February to September 2017 at tertiary care settings in Kuala Lumpur, Malaysia. Patients aged 18 years and above, undergoing hemodialysis, understanding Malay language and willing to participate were included. The CKD-associated pruritus was assessed by using Malay 5D-itch scale and Malay FANLTC questionaiare. To determine the factors associated with pruritus and quality of life, multivariate logistic regression analysis was used having P value < 0.05 as statistically significant. Among n = 334 recruited patients with a response rate of 100%, 59.6% were males and total of 61.3% were having CKD-associated pruritus. The results showed a statistically significant weak negative correlation between CKD-associated pruritus and quality of life. Multivariate linear regression revealed none of these factors were found to be associated with pruritus; however, CKD-associated prurtius was found to be associated with quality of life score. CKD-associated pruritus is have a negative impact on the patient's quality of life including physical, social, mental/emotional, and functional well-being. Despite the high prevalence and negative impact of CKD-associated pruritus on quality of life, it is disregarded by most health care professionals. It is thus pertinent to monitor the potential risk factors and consider providing timely treatment implications for CKD-associated pruritus in hemodialysis patients, in order to improve their quality of life.
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Affiliation(s)
- Inayat U Rehman
- School of Pharmacy, Monash University, Bandar Sunway, Malaysia.,Department of Pharmacy, Abdul Wali Khan University Mardan, Mardan, Pakistan
| | - Pauline Sm Lai
- Department of Primary Care Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Lim S Kun
- Department of Nephrology, University of Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Learn H Lee
- School of Pharmacy, Monash University, Bandar Sunway, Malaysia.,Biomedical Research Laboratory, Jeffrey Cheah School of Medicine and Health Sciences, Monash University, Bandar Sunway, Malaysia.,Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | - Kok G Chan
- International Genome Centre, Jiangsu University, Zhenjiang, China.,ISB (Genetics), Faculty of Science, University of Malaya, Kuala Lumpur, Malaysia
| | - Tahir M Khan
- School of Pharmacy, Monash University, Bandar Sunway, Malaysia.,Institute of Pharmaceutical Sciences, University of Veterinary and Animal Science, Lahore, Pakistan
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Rehman IU, Lai PSM, Lim SK, Lee LH, Khan TM. Sleep disturbance among Malaysian patients with end-stage renal disease with pruritus. BMC Nephrol 2019; 20:102. [PMID: 30909887 PMCID: PMC6434782 DOI: 10.1186/s12882-019-1294-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 03/13/2019] [Indexed: 11/24/2022] Open
Abstract
Background Chronic kidney disease-associated pruritus (CKD-aP) is a well-recognized, frequent and compromising complication among patients on hemodialysis. Despite advancement in basic medical sciences, CKD-aP is still a major complication and a challenge for both physicians and patients to manage. The aim of this study was to estimate the prevalence of CKD-aP among hemodialysis patients in Malaysia, to determine the impact of CKD-aP on sleep quality and any factors associated with CKD-aP. Method A multi-centered, cross-sectional study design was conducted from February 2017 to September 2017 at a tertiary hospital and its affiliated dialysis centers, in Kuala Lumpur, Malaysia. Included were patients > 18 years of age who were undergoing hemodialysis and could understand Malay. Participants were asked to fill the Malay 5D-itch scale and the Malay Pittsburgh sleep quality index (PSQI) upon recruitment. Results A total of 334/334 patients were recruited (response rate = 100%). The majority were male (59.6%) and Chinese (61.7%). A total of 61.3% had pruritus, of which most patients (63.4%) reported that their pruritus was mild. More than half (54.1%) reported that they slept > 6 h, and 93.2% experienced no sleep disturbances during the night. However; the overall PSQI median score [IQR] was 6.0 [5.0–9.0]. No significant association was found between demographic and clinical characteristics of patients with the severity of pruritus. Patients with moderate to severe pruritus were found to be 5.47 times more likely to experience poor sleep quality as compared to patients with mild or no pruritus. Conclusion In Malaysia, the prevalence of CKD-aP was 61.3%, of which the majority reported that their pruritus was mild. Patients with moderate to severe pruritus were found to be 5.47 times more likely to experience poor sleep quality as compared to patients with mild or no pruritus.
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Affiliation(s)
- Inayat Ur Rehman
- School of Pharmacy, Monash University, Jalan Lagoon Selatan, Bandar Sunway, 47500, Selangor Darul Ehsan, Malaysia. .,Department of Pharmacy, Abdul Wali Khan University Mardan, Mardan, Pakistan.
| | - Pauline Siew Mei Lai
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Soo Kun Lim
- Department of Medicine (Division of Nephrology), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Learn Han Lee
- School of Pharmacy, Monash University, Jalan Lagoon Selatan, Bandar Sunway, 47500, Selangor Darul Ehsan, Malaysia.,Novel Bacteria and Drug Discovery Research Group, Microbiome and Bioresource Research Strength, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, 47500, Bandar Sunway, Selangor Darul Ehsan, Malaysia.,Institute of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, 510006, Guangzhou, People's Republic of China.,Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | - Tahir Mehmood Khan
- School of Pharmacy, Monash University, Jalan Lagoon Selatan, Bandar Sunway, 47500, Selangor Darul Ehsan, Malaysia. .,Institute of Pharmaceutical Sciences, University of Veterinary and Animal Science, Outfall Campus, Civil Lines, Lahore, Pakistan.
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Altınok Ersoy N, Akyar İ. Multidimensional pruritus assessment in hemodialysis patients. BMC Nephrol 2019; 20:42. [PMID: 30727999 PMCID: PMC6366049 DOI: 10.1186/s12882-019-1234-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Accepted: 01/28/2019] [Indexed: 12/02/2022] Open
Abstract
Background Pruritus is a distressing, life-limiting symptom in chronic renal failure, affecting 40% of patients. This study aimed to determine uremic pruritus prevalence and investigate the multidimensional impact on hemodialysis patients. Methods This descriptive study was performed between March and June 2016. The study included 181 patients undergoing hemodialysis session, who reported pruritus in the prior month. Data were collected using the 5-D Itch Scale, which assesses pruritus based on 5 dimensions, i.e., degree, duration, direction, disability, and distribution, with a total score ranging from 5 (no itching) to 25 (maximum severity). Results Pruritus prevalence was 49.3%. Patients had a mean score of 13.97 ± 4.11 (moderate severity). The daily duration was 6–12 h (40.3%), with direction “a little bit better but still present” (38.7%) and distribution on the “back, upper arms, chest, and abdomen.” Patients sleep, social life/leisure time, housework and errand were impacted “occasionally”. The score was higher in patients aged ≥65 years, those on hemodialysis for ≥15 or more years, and those undergoing afternoon hemodialysis. The duration of itching was significantly shorter in employed patients. Conclusion Assessment and management of itching symptoms in chronic renal failure are a clinical priority both for patients and for health care professionals. The results of this study highlight the importance of multidimensional assessment and support the need for development of standardized and patient-specific symptom management.
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Affiliation(s)
- Nese Altınok Ersoy
- Medical Nursing Department, Hacettepe University Faculty of Nursing, Sihhiye/Ankara, Turkey.
| | - İmatullah Akyar
- Medical Nursing Department, Hacettepe University Faculty of Nursing, Sihhiye/Ankara, Turkey
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Rehman IU, Munib S, Ramadas A, Khan TM. Prevalence of chronic kidney disease-associated pruritus, and association with sleep quality among hemodialysis patients in Pakistan. PLoS One 2018; 13:e0207758. [PMID: 30496235 PMCID: PMC6264857 DOI: 10.1371/journal.pone.0207758] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 11/06/2018] [Indexed: 12/27/2022] Open
Abstract
Background The prevalence of chronic kidney disease-associated pruritus (CKD-aP) varies from 22% to 84% among patients receiving hemodialysis. It occurs more frequently at night, and often affects patient’s sleep quality. CKD-aP is often unreported by patients, and many do not receive effective treatment. There is, however, a paucity of available data on the prevalence and impact of CKD-aP on patients receiving hemodialysis in Pakistan. Methods A multicenter cross-sectional study was undertaken from July 2016 to April 2017 at a tertiary care hospitals in Pakistan. Results 354 patients undergoing hemodialysis were studied. 35.6% had CKD for 1–2 years, and 42.4% were receiving hemodialysis for 1–2 years. The prevalence of pruritus was 74%. The median [interquartile range] score for pruritus was 10.0 (out of possible 25) [8.0–12.0]; while the median [interquartile range] Pittsburgh Sleep Quality Index (PSQI) score was 8.0 (out of possible 21) [7.0–10.0]'. Pruritus was significantly correlated with the sleep score (r = 0.423, p<0.001). The results of the multivariate linear regression revealed a positive association between pruritus and age of patients (β = 0.031; 95% CI = 0.002–0.061; p = 0.038) and duration of CKD (β = -0.013; 95% CI = -0.023 –-0.003; p = 0.014). Similarly there was a positive association between sleep score and duration of CKD (β = 0.010; 95% CI = 0.002–0.019; p = 0.012) and pruritus (β = 0.143; 95% CI = 0.056–0.230; p = 0.001). Conclusions Chronic kidney disease-associated pruritus is very common in patients receiving hemodialysis in Pakistan. Pruritus is significantly associated with poor sleep quality.
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Affiliation(s)
- Inayat Ur Rehman
- School of Pharmacy, Monash University, Jalan Lagoon Selatan, Selangor Darul Ehsan, Malaysia
- Department of Pharmacy, Abdul Wali Khan University, Mardan, Pakistan
- * E-mail: (TMK); (IUR)
| | - Syed Munib
- Department of Nephrology, Institute of Kidney diseases, Peshawar, Pakistan
| | - Amutha Ramadas
- Jeffrey Cheah School of Medicine & Health Sciences, Monash University Malaysia, Jalan Lagoon Selatan, Selangor Darul Ehsan, Malaysia
| | - Tahir Mehmood Khan
- School of Pharmacy, Monash University, Jalan Lagoon Selatan, Selangor Darul Ehsan, Malaysia
- Institute of Pharmaceutical Sciences (IPS), University of Veterinary & Animal Sciences (UVAS), Lahore, Pakistan
- * E-mail: (TMK); (IUR)
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Hsu CW, Weng CH, Chan MJ, Lin-Tan DT, Yen TH, Huang WH. Association Between Serum Aluminum Level and Uremic Pruritus in Hemodialysis Patients. Sci Rep 2018; 8:17251. [PMID: 30467375 PMCID: PMC6250692 DOI: 10.1038/s41598-018-35217-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 10/31/2018] [Indexed: 12/17/2022] Open
Abstract
Uremic pruritus (UP) is a common symptom in patients undergoing hemodialysis (HD). The pathogenesis of UP is complex. Aluminum (Al) is a common metal and is toxic to patients undergoing HD. Al is also a known human allergen which can induce immune reactions. However, the correlation between Al and UP remains unclear in dialysis patients. A total of 866 patients on maintenance HD were enrolled for analysis. The HD patients with higher serum Al levels had higher a prevalence of UP than those with lower serum Al levels. After adjusting for confounding variables, the serum Al level was significantly associated with UP. Overall, each 10-fold increase in serum Al level was associated with a 5.64-fold increase in the risk of developing UP in these subjects. The results of this cross-sectional study suggest that serum Al level may be associated with the development of UP in patients on maintenance HD.
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Affiliation(s)
- Ching-Wei Hsu
- Department of Nephrology and Clinical Poison Center, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Cheng-Hao Weng
- Department of Nephrology and Clinical Poison Center, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ming-Jen Chan
- Department of Nephrology and Clinical Poison Center, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Dan-Tzu Lin-Tan
- Department of Nephrology and Clinical Poison Center, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Tzung-Hai Yen
- Department of Nephrology and Clinical Poison Center, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Wen-Hung Huang
- Department of Nephrology and Clinical Poison Center, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan. .,Chang Gung University College of Medicine, Taoyuan, Taiwan.
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40
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Wu HY, Huang JW, Tsai WC, Peng YS, Chen HY, Yang JY, Hsu SP, Pai MF, Ko MJ, Hung KY, Chiu HC. Prognostic importance and determinants of uremic pruritus in patients receiving peritoneal dialysis: A prospective cohort study. PLoS One 2018; 13:e0203474. [PMID: 30183756 PMCID: PMC6124771 DOI: 10.1371/journal.pone.0203474] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 08/21/2018] [Indexed: 11/18/2022] Open
Abstract
Background Uremic pruritus is a common and frustrating symptom among patients receiving peritoneal dialysis (PD). This study aimed to examine the prognostic importance of uremic pruritus and to identify the determinants for higher pruritus intensity in PD patients. Methods We conducted a prospective cohort study of patients receiving maintenance PD. A visual analogue scale (VAS) score was used to measure the intensity of uremic pruritus. The composite endpoint of PD technique failure or all-cause death was assessed using a multivariable Cox proportional hazards model. The determinants for the VAS score of uremic pruritus was assessed using a multivariable linear regression model. Results Among the 85 PD patients, 24 (28%) had uremic pruritus. During a median follow-up of 28.0 months, 12 patients experienced technique failure, and 7 died. We found that a higher VAS score of pruritus intensity was an independent risk factor for technique failure or death (hazard ratio, 1.64; 95% confidence interval, 1.18 to 2.28; P = 0.003) after adjusting for a variety of confounding factors. We also found that a weekly total Kt/V of less than 1.88, a longer duration of dialysis, a higher dietary protein intake, and higher blood levels of intact parathyroid hormone and high-sensitivity C-reactive protein were independent determinants of higher VAS scores of pruritus intensity. Conclusions Our results show that uremic pruritus is an independent risk factor of technique failure and death in patients receiving PD. We also found that a weekly total Kt/V < 1.88 is associated with higher intensity of uremic pruritus in PD patients.
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Affiliation(s)
- Hon-Yen Wu
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei City, Taiwan
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei City, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
| | - Jenq-Wen Huang
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
| | - Wan-Chuan Tsai
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei City, Taiwan
- Department of Marketing and Distribution Management, Oriental Institute of Technology, New Taipei City, Taiwan
| | - Yu-Sen Peng
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
| | - Hung-Yuan Chen
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
| | - Ju-Yeh Yang
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
| | - Shih-Ping Hsu
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
| | - Mei-Fen Pai
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
| | - Mei-Ju Ko
- Department of Dermatology, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
- Department of Dermatology, Taipei City Hospital, Taipei City, Taiwan
- * E-mail:
| | - Kuan-Yu Hung
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu City, Taiwan
| | - Hsien-Ching Chiu
- Department of Dermatology, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
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Hu X, Sang Y, Yang M, Chen X, Tang W. Prevalence of chronic kidney disease-associated pruritus among adult dialysis patients: A meta-analysis of cross-sectional studies. Medicine (Baltimore) 2018; 97:e10633. [PMID: 29794739 PMCID: PMC6392722 DOI: 10.1097/md.0000000000010633] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Chronic kidney disease (CKD)-associated pruritus is a common adverse symptom in patients with end-stage renal disease treated by dialysis. Herein, a systematic review and meta-analysis of the prevalence of CKD-associated pruritus among adult dialysis patients was conducted.An electronic search of PubMed, Web of Science, Elsevier, Wanfang, and Chinese National Knowledge Infrastructure databases was conducted from inception to November 23, 2016, and all cross-sectional studies that reported the prevalence of CKD-associated pruritus in dialysis were collected. The pooled prevalence was estimated by random-effects model. Potential publication bias was evaluated by the funnel plot as well as Begg and Egger tests.After rigorous screening, a total of 42 studies conducted on 11,800 patients were included in this study. The overall prevalence of CKD-associated pruritus among adult dialysis patients was 55% (95% confidence interval [CI], 49-61, I = 97.6%), the stratification of which was 55% (95% CI, 45-65, I = 94.7%) in men and 55% (95% CI, 46-65, I = 93.3%) in women. In hemodialysis (HD) patients, the prevalence of CKD-associated pruritus was 55% (95% CI, 49-62, I = 97.9%), while in peritoneal dialysis (PD) patients, it was 56% (95% CI, 44-68, I = 89.9%). The prevalence of CKD-associated pruritus for mean dialysis duration <40 months was 56% (95% CI, 48-63, I = 75.1%), while that for mean dialysis duration ≥40 months was 50% (95% CI, 36-64, I = 99.1%).The prevalence of CKD-associated pruritus is high in HD and PD. The prevalence among adult dialysis patients is comparable between China and foreign countries as well as between females and males. Studies with the similar disease definition and analysis of the effects of risk factors on CKD-associated pruritus are needed.
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Affiliation(s)
- Xinmiao Hu
- Department of General Surgery, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai
| | - Yan Sang
- Department of Nursing, Affiliated Hospital of Nantong University
| | - Mei Yang
- Department of Ophthalmology, Affiliated Hospital of Nantong University, Nantong
| | - Xue Chen
- Art College, Nanjing Audit University, Nanjing, Jiangsu, China
| | - Wenjuan Tang
- Department of General Surgery, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai
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Tattersall J, Farrington K, Gentile G, Kooman J, Macias Núñez JF, Nistor I, Van Biesen W, Covic A. Is Kt/V useful in elderly dialysis patients? Pro and Con arguments. Nephrol Dial Transplant 2018; 33:742-750. [DOI: 10.1093/ndt/gfy042] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 02/04/2018] [Indexed: 01/06/2023] Open
Affiliation(s)
- James Tattersall
- Renal Unit, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ken Farrington
- Renal Unit, Lister Hospital, Stevenage, Hertfordshire, UK
- Centre for Health Services and Clinical Research, University of Hertfordshire, Hatfield, UK
| | - Giorgio Gentile
- Department of Renal Medicine, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Jeroen Kooman
- Division of Nephrology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Ionut Nistor
- Department of Nephrology “Dr CI Parhon” Hospital, Iasi, Romania
| | - Wim Van Biesen
- Department of Nephrology, Ghent University Hospital, Ghent, Belgium
| | - Adrian Covic
- Department of Nephrology “Dr CI Parhon” Hospital, Iasi, Romania
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Millington G, Collins A, Lovell C, Leslie T, Yong A, Morgan J, Ajithkumar T, Andrews M, Rushbook S, Coelho R, Catten S, Lee K, Skellett A, Affleck A, Exton L, Mohd Mustapa M, Levell N, McHenry P, Gibbon K, Buckley D, Leslie T, Mallon E, Wakelin S, Ungureanu S, Hunasehally R, Cork M, Johnston G, Chiang N, Natkunarajah J, Worsnop F, Duarte Williamson C, Donnelly J, Towers K, Saunders C, Adbi Salad A, Brain A. British Association of Dermatologists’ guidelines for the investigation and management of generalized pruritus in adults without an underlying dermatosis, 2018. Br J Dermatol 2018; 178:34-60. [DOI: 10.1111/bjd.16117] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2017] [Indexed: 12/20/2022]
Affiliation(s)
- G.W.M. Millington
- Dermatology Department Norfolk and Norwich University Hospital Colney Lane Norwich NR4 7UY U.K
| | - A. Collins
- Haematology Department Norfolk and Norwich University Hospital Colney Lane Norwich NR4 7UY U.K
| | - C.R. Lovell
- Dermatology Department Royal United Hospital Combe Park Bath BA1 3NG U.K
| | - T.A. Leslie
- Dermatology Department Royal Free Hospital Pond Street London NW3 2QGU.K
| | - A.S.W. Yong
- Dermatology Department Norfolk and Norwich University Hospital Colney Lane Norwich NR4 7UY U.K
| | - J.D. Morgan
- General Practitioner Chet Valley Medical Practice 40–48 George Lane London NR14 6QH U.K
| | - T. Ajithkumar
- Oncology Department Addenbrooke's Hospital Hills Road Cambridge CB2 2QQ U.K
| | - M.J. Andrews
- Nephrology Department Norfolk and Norwich University Hospital Colney Lane Norwich NR4 7UY U.K
| | - S.M. Rushbook
- Hepatology Unit Norfolk and Norwich University Hospital Colney Lane Norwich NR4 7UY U.K
| | - R.R. Coelho
- Dermatology Department St George's Hospital Blackshaw Road London SW17 0QT U.K
| | - S.J. Catten
- Dermatology Department Norfolk and Norwich University Hospital Colney Lane Norwich NR4 7UY U.K
| | - K.Y.C. Lee
- Dermatology Department Norfolk and Norwich University Hospital Colney Lane Norwich NR4 7UY U.K
| | - A.M. Skellett
- Dermatology Department Norfolk and Norwich University Hospital Colney Lane Norwich NR4 7UY U.K
| | - A.G. Affleck
- Dermatology Department Ninewells Hospital Dundee DD1 9SY U.K
| | - L.S. Exton
- British Association of Dermatologists Willan House 4 Fitzroy Square London W1T 5HQ U.K
| | - M.F. Mohd Mustapa
- British Association of Dermatologists Willan House 4 Fitzroy Square London W1T 5HQ U.K
| | - N.J. Levell
- Dermatology Department Norfolk and Norwich University Hospital Colney Lane Norwich NR4 7UY U.K
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Wu Q, Zhang H, Ding JR, Hong ZY, Wu H, Zhu ZY, Guo ZY, Chai YF. UPLC-QTOF MS-Based Serum Metabolomic Profiling Analysis Reveals the Molecular Perturbations Underlying Uremic Pruritus. BIOMED RESEARCH INTERNATIONAL 2018; 2018:4351674. [PMID: 29546058 PMCID: PMC5818897 DOI: 10.1155/2018/4351674] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 08/02/2017] [Accepted: 11/14/2017] [Indexed: 01/19/2023]
Abstract
As one of the most troublesome complications in patients with chronic renal disease, the etiology of uremic pruritus remains unknown, and the current therapeutic approaches are limited and unsatisfactory. To identify potential biomarkers for improving diagnosis and treatment and obtain a better understanding of the pathogenesis of uremic pruritus, we compared serum metabolome profiles of severe uremic pruritus (HUP) patients with mild uremic pruritus (LUP) patients using ultraperformance liquid chromatography-quadruple time-of-flight mass spectrometry (UPLC-QTOF MS). Partial least squares discriminant analysis (PLS-DA) showed that the metabolic profiles of HUP patients are distinguishable from those of LUP patients. Combining multivariate with univariate analysis, 22 significantly different metabolites between HUP and LUP patients were identified. Nine of the 22 metabolites in combination were characterized by a maximum area-under-receiver operating characteristic curve (AUC = 0.899) with a sensitivity of 85.1% and a specificity of 83.0% distinguishing HUP and LUP. Our results indicate that serum metabolome profiling might serve as a promising approach for the diagnosis of uremic pruritus and that the identified biomarkers may improve the understanding of pathophysiology of this disorder. Because the 9 metabolites were phospholipids, uremic toxins, and steroids, further studies may reveal their possible role in the pathogenesis of uremic pruritus.
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Affiliation(s)
- Qiong Wu
- School of Pharmacy, Second Military Medical University, Shanghai 200433, China
| | - Huan Zhang
- Department of Nephrology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Jia-rong Ding
- Department of Nephrology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Zhan-ying Hong
- School of Pharmacy, Second Military Medical University, Shanghai 200433, China
| | - Hao Wu
- Department of Nephrology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Zhen-yu Zhu
- Analysis and Measurement Center, School of Pharmacy, Second Military Medical University, Shanghai 200433, China
| | - Zhi-yong Guo
- Department of Nephrology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Yi-feng Chai
- School of Pharmacy, Second Military Medical University, Shanghai 200433, China
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45
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Wong LS, Wu T, Lee CH. Inflammatory and Noninflammatory Itch: Implications in Pathophysiology-Directed Treatments. Int J Mol Sci 2017; 18:E1485. [PMID: 28698528 PMCID: PMC5535975 DOI: 10.3390/ijms18071485] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 07/01/2017] [Accepted: 07/05/2017] [Indexed: 12/13/2022] Open
Abstract
Itch is the main chief complaint in patients visiting dermatologic clinics and has the ability to deeply impair life quality. Itch results from activation of cutaneous nerve endings by noxious stimuli such as inflammatory mediators, neurotransmitters and neuropeptides, causing itch signal transduction from peripheral skin, through the spinal cord and thalamus, to the brain cortex. Primarily noninflammatory diseases, such as uremic pruritus, cause itch through certain pruritogens in the skin. In inflammatory skin diseases, atopic dermatitis (AD) is the prototypic disease causing intensive itch by aberrant skin inflammation and epidermal barrier disruption. Recent understanding of disease susceptibility, severity markers, and mechanisms have helped to develop targeted therapy for itch in AD, including monoclonal antibodies against IL-4, IL-13, thymic stromal lymphopoietin (TSLP), IgE and IL-31. Promising effects have been observed in some of them. In this review, we summarized targeted therapies for inflammatory itch in AD and for managing abnormal itch transductions in other common itching skin diseases.
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Affiliation(s)
- Lai-San Wong
- Department of Dermatology, College of Medicine, Chang Gung Memorial Hospital and Chang Gung University, Kaohsiung 833, Taiwan.
| | - Tiffany Wu
- Zanvyl Kreiger School of Arts and Sciences, Johns Hopkins University, Baltimore, MD 21287, USA.
| | - Chih-Hung Lee
- Department of Dermatology, College of Medicine, Chang Gung Memorial Hospital and Chang Gung University, Kaohsiung 833, Taiwan.
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Orasan OH, Saplontai AP, Cozma A, Racasan S, Kacso IM, Rusu CC, Moldovan D, Tirinescu D, Potra A, Patiu IM, Orasan RA. Insomnia, muscular cramps and pruritus have low intensity in hemodialysis patients with good dialysis efficiency, low inflammation and arteriovenous fistula. Int Urol Nephrol 2017; 49:1673-1679. [PMID: 28534129 DOI: 10.1007/s11255-017-1624-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 05/16/2017] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Insomnia, muscular cramps, pruritus and postdialysis recovery time (RT) are quality-of-life parameters that affect hemodialysis (HD) patients physically and mentally. METHODS We included 171 end-stage renal disease patients: 115 on high-flux HD and 56 on online hemodiafiltration (HDF). Patients were asked "How long does it take you to recover from a dialysis session?" and they evaluated intensity (absent, mild, medium and severe) of insomnia, muscular cramps and pruritus in the past 4 weeks. We sought associations of RT, insomnia, muscular cramps and pruritus with themselves and age, dialysis vintage, sex, body mass index, hemoglobin, albumin, C-reactive protein (CRP), Daugirdas single-pool Kt/V (Kt/V), ultrafiltration volume, blood processed volume and vascular access type. RESULTS Insomnia absence correlated with muscular cramps absence (p = 0.01), arteriovenous fistula (AVF) presence (p = 0.02) and lower CRP (p = 0.003). Muscular cramps absence associated pruritus absence (p = 0.007) and AVF (p = 0.001). Absent pruritus patients were younger (p = 0.04), had higher Kt/V (p = 0.01) and more AVF (p = 0.02). Men insomnia was more severe in HD than HDF and albumin related (p = 0.007), while CRP was lower in absent pruritus. Women insomnia associated with muscular cramps (p = 0.04) and vascular access (p = 0.03), as was pruritus (p = 0.03). RT had no relations with any parameter. CONCLUSIONS HD patients with AVF have less insomnia, muscular cramps and pruritus. Insomnia is associated with muscular cramps and inflammation. Pruritus is worse in older patients, is diminished with increased dialysis efficiency and is associated with higher CRP in men. There is no difference between HD and HDF patients, except more severe insomnia for HD in men.
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Affiliation(s)
- Olga Hilda Orasan
- 4th Medical Department, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania
| | - Aniela Pop Saplontai
- 5th Medical Department, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania
| | - Angela Cozma
- 4th Medical Department, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania
| | | | - Ina Maria Kacso
- Department of Nephrology, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania
| | - Crina Claudia Rusu
- Department of Nephrology, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania
| | - Diana Moldovan
- Department of Nephrology, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania
| | - Dacian Tirinescu
- Department of Nephrology, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania
| | - Alina Potra
- Department of Nephrology, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania
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Hayani K, Kunzmann K, Mettang T, Weiss M, Tschulena U, Weisshaar E. Lower prevalence of chronic itch in haemodialysis patients on loop diuretics: results from GEHIS (German Epidemiological Hemodialysis Itch Study). J Eur Acad Dermatol Venereol 2017; 31:1333-1337. [PMID: 28252810 DOI: 10.1111/jdv.14189] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 02/09/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Chronic itch (CI) is a very tormenting symptom in haemodialysis (HD) patients. GEHIS (German Epidemiological Hemodialysis Itch Study) is a representative cross-sectional study showing that current chronic itch (CI) affects 25.2% of haemodialysis (HD) patients. OBJECTIVE We investigated drug intake and possible associations between CI and medications of HD patients. METHODS Eight hundred and sixty HD patients from a randomly selected cluster sample of 25 dialysis units (GEHIS) in Germany were investigated. Statistical analyses were performed using R (version 3.3.0) for Windows. Logistic regression was used to identify influential covariates for prevalence of chronic itch and intensity of itch. RESULTS Taking loop diuretics (furosemide, torasemide) was significantly negatively associated with the occurrence of CI in HD patients meaning that those who had received any type of loop diuretics were significantly less likely to suffer from less CI compared to those who had not taken them. There were no associations of CI with other medications. No correlation was detected between the intensity of itch and the intake of loop diuretics or any other medication. CONCLUSION Loop diuretics may have an impact on the development of CI in HD patients. As it is most likely that a multifactorial origin may explain CI in HD, future research should also focus on the role of loop diuretics in CI, both on a clinical as well as on a molecular level.
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Affiliation(s)
- K Hayani
- Department of Clinical Social Medicine, Occupational and Environmental Dermatology, Ruprecht-Karls University, Heidelberg, Germany
| | - K Kunzmann
- Department of Medical Biometry and Informatics, Ruprecht-Karls University, Heidelberg, Germany
| | - T Mettang
- Department of Nephrology, DKD Helios Klinik, Wiesbaden, Germany
| | - M Weiss
- Department of Clinical Social Medicine, Occupational and Environmental Dermatology, Ruprecht-Karls University, Heidelberg, Germany
| | - U Tschulena
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - E Weisshaar
- Department of Clinical Social Medicine, Occupational and Environmental Dermatology, Ruprecht-Karls University, Heidelberg, Germany
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Shirazian S, Aina O, Park Y, Chowdhury N, Leger K, Hou L, Miyawaki N, Mathur VS. Chronic kidney disease-associated pruritus: impact on quality of life and current management challenges. Int J Nephrol Renovasc Dis 2017; 10:11-26. [PMID: 28176969 PMCID: PMC5271405 DOI: 10.2147/ijnrd.s108045] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Chronic kidney disease-associated pruritus (CKD-aP) is a distressing, often overlooked condition in patients with CKD and end-stage renal disease. It affects ~40% of patients with end-stage renal disease and has been associated with poor quality of life, poor sleep, depression, and mortality. Prevalence estimates vary based on the instruments used to diagnose CKD-aP, and standardized diagnostic instruments are sorely needed. Treatment studies have often yielded conflicting results. This is likely related to studies that are limited by small sample size, flawed designs, and nonstandardized diagnostic instruments. Several large well-designed treatment trials have recently been completed and may soon influence CKD-aP management.
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Affiliation(s)
- Shayan Shirazian
- Division of Nephrology, Department of Medicine, Winthrop University Hospital, Mineola, NY
| | - Olufemi Aina
- Division of Nephrology, Department of Medicine, Winthrop University Hospital, Mineola, NY
| | - Youngjun Park
- Division of Nephrology, Department of Medicine, Winthrop University Hospital, Mineola, NY
| | - Nawsheen Chowdhury
- Division of Nephrology, Department of Medicine, Winthrop University Hospital, Mineola, NY
| | - Kathleen Leger
- Division of Nephrology, Department of Medicine, Winthrop University Hospital, Mineola, NY
| | - Linle Hou
- Division of Nephrology, Department of Medicine, Winthrop University Hospital, Mineola, NY
| | - Nobuyuki Miyawaki
- Division of Nephrology, Department of Medicine, Winthrop University Hospital, Mineola, NY
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Nemati E, Khosravi A, Einollahi B, Meshkati M, Taghipour M, Abbaszadeh S. The relationship between dialysis adequacy and serum uric acid in dialysis patients; a cross-sectional multi-center study in Iranian hemodialysis centers. J Renal Inj Prev 2016; 6:142-147. [PMID: 28497092 PMCID: PMC5423283 DOI: 10.15171/jrip.2017.28] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 12/02/2016] [Indexed: 11/15/2022] Open
Abstract
Introduction: Uric acid is one of the most significant uremic toxins accumulating in chronic renal failure patients treated with standard dialysis. Its clearance has not any exact relation with urea and creatinine clearance.
Objectives: The aim of this study was to investigate the relationship between adequacy of dialysis and serum level of uric acid in dialysis patients of some dialysis centers in Iran.
Patients and Methods: In this study 1271 hemodialysis patients who have been treated for more than 3 months were evaluated. Their information and examinations from their files in all over the country were gathered and analyzed using SPSS versin18.0.
Results: In this study, a significant relationship between dialysis duration and serum level of uric acid was not detected, however, a significant relationship between patients Kt/V and uric acid (R=0.43, P=0.029) was seen. Patients who had higher adequacy of dialysis had a higher level of plasma uric acid.
Conclusion: For better controlling of plasma uric acid level of hemodialysis patients, increasing of the adequacy of dialysis or its duration is not effective. Other modalities of decreasing of serum uric acid like, changing diet or lifestyle or medical therapy may be necessary.
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Affiliation(s)
- Eghlim Nemati
- Nephrology and Urology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Arezoo Khosravi
- Atherosclrosis Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Behzad Einollahi
- Nephrology and Urology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Mehdi Meshkati
- Faculty of Medicine, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Mehrdad Taghipour
- Nephrology and Urology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Shahin Abbaszadeh
- Nephrology and Urology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
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Scherer JS, Combs SA, Brennan F. Sleep Disorders, Restless Legs Syndrome, and Uremic Pruritus: Diagnosis and Treatment of Common Symptoms in Dialysis Patients. Am J Kidney Dis 2016; 69:117-128. [PMID: 27693261 DOI: 10.1053/j.ajkd.2016.07.031] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 07/06/2016] [Indexed: 11/11/2022]
Abstract
Maintenance dialysis patients experience a high burden of physical and emotional symptoms that directly affect their quality of life and health care utilization. In this review, we specifically highlight common troublesome symptoms affecting dialysis patients: insomnia, restless legs syndrome, and uremic pruritus. Epidemiology, pathophysiology, and evidence-based current treatment are reviewed with the goal of providing a guide for diagnosis and treatment. Finally, we identify multiple additional areas of further study needed to improve symptom management in dialysis patients.
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Affiliation(s)
- Jennifer S Scherer
- Division of Palliative Care, NYU School of Medicine, New York, NY; Division of Nephrology, NYU School of Medicine, New York, NY.
| | - Sara A Combs
- Division of Nephrology, Department of Medicine, VA Eastern Colorado Health Care System, University of Colorado School of Medicine, Denver, CO; Division of Palliative Care, Department of Medicine, VA Eastern Colorado Health Care System, University of Colorado School of Medicine, Denver, CO
| | - Frank Brennan
- Department of Nephrology, St. George Hospital, Kogarah, New South Wales, Australia
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