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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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Fotheringham J, Guest J, Latus J, Lerma E, Morin I, Schaufler T, Soro M, Ständer S, Zeig S. Impact of Difelikefalin on the Health-Related Quality of Life of Haemodialysis Patients with Moderate-To-Severe Chronic Kidney Disease-Associated Pruritus: A Single-Arm Intervention Trial. THE PATIENT 2024; 17:203-213. [PMID: 38196014 PMCID: PMC10894140 DOI: 10.1007/s40271-023-00668-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/10/2023] [Indexed: 01/11/2024]
Abstract
OBJECTIVE Chronic kidney disease-associated pruritus (CKD-aP) can have a substantial negative impact on health-related quality of life (HRQoL), including an increased risk of depression, anxiety and sleep disturbance. This trial aimed to assess the impact of intravenous difelikefalin on HRQoL in haemodialysis patients with moderate-to-severe CKD-aP. METHODS Post hoc analysis of an open-label, multicentre, single-arm intervention trial assessed pruritus severity and HRQoL at baseline and at 12 weeks of difelikefalin treatment using Worst Itching Intensity Numerical Rating Scale (WI-NRS), Sleep Quality Numeric Rating Scale (SQ-NRS), 5-D itch scale, Skindex-10 scale, EQ-5D-5L with Pruritus Bolt-On (EQ-PSO). RESULTS A total of 222 patients received ≥ 1 dose of difelikefalin, and 197 patients completed 12 weeks of difelikefalin treatment. Clinically meaningful changes from baseline to 12 weeks were observed in all disease-specific measures: 73.7% of patients achieved a ≥ 3-point reduction in the weekly mean of 24 h WI-NRS scores and 66% of patients experienced ≥ 3-point improvements in SQ-NRS scores. Improvements were also observed in all Skindex-10 scale and 5-D itch scale domain scores. The percentage of patients reporting no problems in all EQ-PSO domains increased from 1.4 to 24.7% (p < 0.001), respectively. Patients' generic HRQoL EQ-5D-5L mean utility and EQ-5D visual analogue scale scores increased from baseline to 12 weeks: mean changes 0.04 (p = 0.001) and 2.8 (p = 0.046), respectively. CONCLUSIONS Patients undergoing haemodialysis with moderate-to-severe CKD-aP receiving difelikefalin reported experiencing clinically meaningful improvements in both their pruritus symptoms and itch-related QoL. CLINICALTRIALS gov registration number, NCT03998163; first submitted, 7 May 2019.
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Affiliation(s)
- James Fotheringham
- School of Health and Related Research, University of Sheffield, Sheffield, UK.
- Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK.
| | | | | | - Edgar Lerma
- Department of Nephrology, Advocate Christ Medical Center, University of Illinois at Chicago, Oak Lawn, IL, USA
| | | | | | | | - Sonja Ständer
- Department of Dermatology, Center for Chronic Pruritus, University Hospital Münster, Münster, Germany
| | - Steven Zeig
- Pines Clinical Research, Pembroke Pines, Hollywood, FL, USA
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Mahmoud RH, Mahmoud O, Yosipovitch G. Intravenous difelikefalin for the treatment of hemodialysis pruritus. Expert Rev Clin Immunol 2024; 20:31-37. [PMID: 37847514 DOI: 10.1080/1744666x.2023.2272048] [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: 07/03/2023] [Accepted: 10/13/2023] [Indexed: 10/18/2023]
Abstract
INTRODUCTION Patients with chronic kidney disease (CKD) undergoing hemodialysis often experience significant itch secondary to their condition and a subsequent reduction in their overall quality of life. Current treatments are underwhelming, necessitating the search for new, effective therapeutic options to combat itch in this population. AREAS COVERED The purpose of this review is to explore the available data for the use of intravenous difelikefalin in patients with CKD undergoing hemodialysis. The pathophysiology of CKD-associated itch is multifactorial, with one proposed mechanism involving an imbalance in the endogenous opioid system, favoring upregulation of itch-activating μ-opioid receptors (MORs) and downregulation of itch-inhibiting κ-opioid receptors (KORs). Dysregulation of the immune system is also involved. Difelikefalin is a recent FDA approved treatment that functions as peripherally acting KOR agonist, targeting this imbalance in the endogenous opioid system seen in CKD patients with itch and having an anti-inflammatory effect on immune cells. Clinical data on intravenous difelikefalin is promising regarding its ability to reduce itch in CKD patients on hemodialysis and improve patient quality of life, with few, mild adverse side effects. EXPERT OPINION As intravenous difelikefalin becomes more widely used in the clinical setting, further studies assessing long-term efficacy and safety will be needed.
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Affiliation(s)
- Rami H Mahmoud
- Dr. Phillip Frost Dept of Dermatology and Cutaneous Surgery, Miami Itch Center, University of Miami Miller School of Medicine, Coral Gables, FL, USA
| | - Omar Mahmoud
- Dr. Phillip Frost Dept of Dermatology and Cutaneous Surgery, Miami Itch Center, University of Miami Miller School of Medicine, Coral Gables, FL, USA
| | - Gil Yosipovitch
- Dr. Phillip Frost Dept of Dermatology and Cutaneous Surgery, Miami Itch Center, University of Miami Miller School of Medicine, Coral Gables, FL, USA
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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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Hernandez Alava M, Sasso A, Hnynn Si PE, Gittus M, Powell R, Dunn L, Thokala P, Fotheringham J. Relationship Between Standardized Measures of Chronic Kidney Disease-associated Pruritus Intensity and Health-related Quality of Life Measured with the EQ-5D Questionnaire: A Mapping Study. Acta Derm Venereol 2023; 103:adv11604. [PMID: 37731210 PMCID: PMC10522326 DOI: 10.2340/actadv.v103.11604] [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: 03/12/2023] [Accepted: 06/29/2023] [Indexed: 09/22/2023] Open
Abstract
Chronic kidney disease-associated pruritus is linked with decreased health-related quality of life assessed using disease-specific instruments. The extent to which worsening pruritus reduces generic quality of life assessed using the EQ-5D instrument is unknown. Prevalent kidney failure patients receiving in-centre haemodialysis from 5 centres completed the EQ-5D-5L quality of life measure, worst Itching Intensity Numerical Rating Scale and 5-D itch pruritus instruments. Latent class models were used to identify clusters of patients with similarly affected body parts, and mixture models were used to map the pruritus measures to the EQ-5D. Data on 487 respondents were obtained. Latent class analysis identified 3 groups of patients who had progressively worsening severity and an increasing number of body parts affected. Although the worst itching intensity numerical rating scale and 5-D itch instruments correlated with each other, only the latter had a strong relationship with EQ-5D. When controlling for age, sex, diabetes and years receiving dialysis, the meanpredicted EQ-5D utility (1: perfect health, 0: dead) decreased progressively from 0.69 to 0.41. These findings suggest that pruritus instruments that include domains capturing how the individual is physically, mentally and socially affected by their pruritus, in addition to severity, more closely approximate the EQ-5D generic quality of life measure.
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Affiliation(s)
| | - Alessandro Sasso
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Pann Ei Hnynn Si
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Matthew Gittus
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Louese Dunn
- Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Praveen Thokala
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - James Fotheringham
- School of Health and Related Research, University of Sheffield, Sheffield, UK.
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