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Jha CM, Dastoor HD, Gopalakrishnan N, Holt SG. Obstacles to Early Diagnosis and Treatment of Pruritus in Patients with Chronic Kidney Disease: Current Perspectives. Int J Nephrol Renovasc Dis 2022; 15:335-352. [PMID: 36510564 PMCID: PMC9739055 DOI: 10.2147/ijnrd.s294147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 11/15/2022] [Indexed: 12/12/2022] Open
Abstract
Chronic kidney disease-associated pruritus (CKD-aP) is a common condition amongst patients with advanced chronic kidney disease (CKD). Several studies have confirmed that more than four out of ten early-stage CKD patients suffer from this condition, while its prevalence among CKD patients on dialysis reaches up to seven out of ten. It is noted to be associated with other disabling symptoms and serious outcomes. It has significant impact on sleep, mood, daily activities, and quality of life of CKD patients, and increased mortality risk of patients on hemodialysis. The Dialysis Outcomes and Practice Patterns Study found 17% higher mortality among patients with moderate to extreme pruritus compared with patients with no or mild pruritus. Despite its high prevalence, ill-effect, and suffering associated with it, CKD-aP remains surprisingly under-reported on the patient's part and under-recognized by the healthcare team. Even upon being noticed, it remains unattended and poorly treated. Its etiopathogenesis is complex and not fully understood. Many treatment options are available but good quality evidence about most of those is absent, and to date, only two medications are approved for use in this condition. While a validated guideline is very much required for the benefit of the patients and caretakers, further research on several aspects of this issue is required.
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Affiliation(s)
- Chandra Mauli Jha
- SEHA Kidney Care, Abu Dhabi, United Arab Emirates,Correspondence: Chandra Mauli Jha, PO Box 61358; Al Bateen Post Office, Abu Dhabi, United Arab Emirates, Tel +971 50 1096 345; +971 2 55 80 482, Email
| | | | | | - Stephen Geoffrey Holt
- SEHA Kidney Care, Abu Dhabi, United Arab Emirates,Khalifa University, Abu Dhabi, United Arab Emirates
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Clinical Efficacy and Safety of Chinese Herbal Medicine in the Treatment of Uremic Pruritus: A Meta-Analysis of Randomized Controlled Trials. Pharmaceuticals (Basel) 2022; 15:ph15101239. [PMID: 36297351 PMCID: PMC9611342 DOI: 10.3390/ph15101239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/26/2022] [Accepted: 10/06/2022] [Indexed: 11/07/2022] Open
Abstract
Uremic pruritus is a disturbing and refractory symptom in patients with advanced chronic kidney disease. Chinese herbal medicine has been reported to alleviate uremic pruritus. To investigate the effects of Chinese herbal medicine, we conducted a systematic review and meta-analysis on patients with uremic pruritus. We searched databases (prior to 3 May 2022) for randomized controlled trials on the effects of Chinese herbal medicine in treating uremic pruritus. Our meta-analysis included 3311 patients from 50 randomized controlled trials. In patients with uremic pruritus, adjunctive Chinese herbal medicine significantly improved overall effectiveness (risk ratio 1.29, 95% CI 1.23 to 1.35), quality of life, renal function, reduced pruritus score, and inflammatory biomarkers compared to control groups with hemodialysis alone or with anti-pruritic treatments. Chinese herbal medicine treatment showed a time-dependent tendency in improving the visual analog scale of dialysis patients. Compared to control groups, no significantly higher risk of adverse events in patients taking Chinese herbal medicine (risk ratio 0.60, 95% CI 0.22 to 1.63). Chinese herbal medicine appears to be effective and safe in complementing the treatment of patients with uremic pruritus.
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High Serum IL-31 Concentration Is Associated with Itch among Renal Transplant Recipients. J Clin Med 2022; 11:jcm11154309. [PMID: 35893400 PMCID: PMC9332266 DOI: 10.3390/jcm11154309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 07/22/2022] [Accepted: 07/23/2022] [Indexed: 02/05/2023] Open
Abstract
Chronic itch (CI) is a common symptom caused by both dermatological and systemic disorders. CI is also a frequent, burdensome symptom among renal transplant recipients (RTR); however, its pathophysiology is not fully understood. The aim of this study was to assess the differences in concentration of IL-31 among itchy RTR. The study was performed on a group of selected 129 RTRs (54 itchy and 75 non-itchy patients). Itch severity was assessed with the use of the numeral rating scale (NRS) and the 4-item itch questionnaire (4IIQ). Every subject had his blood drawn to measure the concentration of IL-31. The results were subsequently compared and correlated. The mean concentration differed significantly between RTR suffering from itch (602.44 ± 534.5 pg/mL), non-itchy RTR (161.49 ± 106.61 pg/mL), and HC (110.33 ± 51.81 pg/mL) (p < 0.001). Post-hoc analysis revealed a statistically significantly increased IL-31 serum concentration in itchy RTR in comparison to the non-itchy RTR group (p < 0.001) and HC (p < 0.001). No significant difference was observed in IL-31 serum levels between non-itchy RTRs and HC. No correlation between IL-31 and itch intensity was found. The results of our study clearly demonstrate the association between IL-31 levels and CI in patients after renal transplantation.
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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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Satti MZ, Arshad D, Javed H, Shahroz A, Tahir Z, Ahmed MMH, Kareem A. Uremic Pruritus: Prevalence and Impact on Quality of Life and Depressive Symptoms in Hemodialysis Patients. Cureus 2019; 11:e5178. [PMID: 31565588 PMCID: PMC6758963 DOI: 10.7759/cureus.5178] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background End-stage renal disease (ESRD) is a major public health problem with many associated symptoms. Uremic pruritus (UP) develops in 40% of patients on hemodialysis and has major effects on the patient’s life. It is also an independent risk factor for increased mortality, and its psychiatric implications remain poorly characterized in our local setup, where it tends to be underdiagnosed and undertreated. Objectives and rationale The study aims to report the prevalence of uremic pruritus in our study population and associate it with various patient parameters, which may define a subset of patients at high risk for this pruritus. We also assess the effects of uremic pruritus on the patient’s quality of life (by using the Dermatology Life Quality Index; DLQI) and depressive symptoms (by using the Public Health Questionnaire; PHQ-9). Materials and methods It was a descriptive, cross-sectional study conducted in the nephrology unit of the multi-organ failure (MOF) center of the Holy Family Hospital (HFH), Rawalpindi, Pakistan, from February 2019 to June 2019, during which 173 male patients on hemodialysis were selected. Informed consent was taken from patients and other skin-related causes of pruritis were excluded. Uremic pruritus was defined as pruritis lasting for at least three months after the onset of ESRD. The 5-D, PHQ-9, and DLQI questionnaires were used to assess pruritis, depressive symptoms, and quality of life, respectively. Their Cronbach's Alpha values for 73 responses were 0.83, 0.81, and 0.71, respectively. The descriptive analysis was performed using SPSS v23.0 (IBM Corp, Armonk, NY, US). Spearman’s rank-order correlation, independent samples t-test, and one-way analysis of variance (ANOVA) were used to analyze study variables. Results The prevalence of uremic pruritus was 49.1%, with many patients having generalized itching. Unemployment and longer disease duration predisposed the patients towards uremic pruritus, as the mean 5-D score in this subset were greater (p<0.05 in the independent samples t-test). The results of one-way ANOVA were significant (p<0.05), indicating higher 5-D scores in worsening categories of depressive symptoms and quality of life. Spearman’s correlation matrix showed that 5-D, PHQ-9, and DLQI scores were strongly correlated with each other. Conclusions The prevalence of uremic pruritus among male hemodialysis patients is high, at 49.1%. It significantly contributes to depressive symptoms and a lower quality of life, which are associated with worse prognosis in hemodialysis patients. Thus, a clinician must keep in mind the psychiatric implications of uremic pruritus and treat it effectively to optimize the patient’s medical care.
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Affiliation(s)
| | - Danish Arshad
- Psychiatry, Rawalpindi Medical University and Allied Hospitals, Rawalpindi, PAK
| | - Hassan Javed
- Psychiatry, Rawalpindi Medical University and Allied Hospitals, Rawalpindi, PAK
| | - Ahmad Shahroz
- Psychiatry, Rawalpindi Medical University and Allied Hospitals, Rawalpindi, PAK
| | - Zeeshan Tahir
- Psychiatry, Rawalpindi Medical University and Allied Hospitals, Rawalpindi, PAK
| | | | - Arslan Kareem
- Internal Medicine, Rawalpindi Medical University and Allied Hospitals, Rawalpindi, PAK
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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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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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Acupuncture Effect on Pruritus in Hemodialysis Patients: A Randomized Clinical Trial. IRANIAN RED CRESCENT MEDICAL JOURNAL 2018. [DOI: 10.5812/ircmj.65521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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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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