Pruritus and quality of life in renal transplant patients

Pruritus in Chronic Kidney Disease: An Update

Chronic kidney disease-associated pruritus (CKDaP) is an often under-diagnosed and under-recognized condition, despite its considerable prevalence within the chronic kidney disease (CKD) population. Universally accepted guidelines are also lacking. The true prevalence of CKDaP worldwide therefore remains unknown, although its negative impact on mortality and health-related quality of life outcomes is very clear. The pathophysiological mechanisms leading to the onset of CKDaP are only partly understood. CKDaP is currently believed to be caused by a multifactorial process, from local skin changes, metabolic alterations, the development of neuropathy and dysregulation of opioid pathways, and psychological factors. Much work has been carried out towards a more systematic and structured approach to clinical diagnosis. Various tools are now available to assess the severity of CKDaP. Many of these tools require greater validation before they can be incorporated into the guidelines and into routine clinical practice. Further efforts are also needed in order to increase the awareness of clinicians and patients so that they can identify the CKDaP signs and symptoms in a timely manner. Currently established treatment options for CKDaP focus on the prevention of xerosis via topical emollients, the optimization of dialysis management, early referral to kidney transplantation if appropriate, oral antihistamine, and a variety of neuropathic agents. Other novel treatment options include the following: topical analgesics, topical tacrolimus, cannabinoid-containing compounds, antidepressants, oral leukotrienes, opioids, and non-pharmacological alternative therapies (i.e., phototherapy, dietary supplements, acupuncture/acupressure). We provide an updated review on the evidence relating to the epidemiology, the pathophysiology, the clinical assessment and diagnosis, and the management of CKDaP.

Psychosocial Burden of Itch among Renal Transplant Recipients

Itch is the most common symptom of chronic dermatoses. Moreover, itch may be associated with systemic disorders. Chronic kidney disease—associated itch (CKD-aI) may affect up to 20% of renal transplant recipients (RTR). The aim of the study was to assess psychosocial burden of itch in RTR. The study was performed on a group of 129 RTR, out of which 54 (41.9%) experienced itch in the previous 3 days. A specially designed questionnaire assessing anxiety, depression, stigmatization, and quality of life was used. Results: Patients suffering from itch in the previous 3 days achieved significantly higher scores in GAD-7 (p < 0.001), BDI (p < 0.001), HADS total score (p < 0.001), HADS Depression (p = 0.004), and HADS Anxiety (p < 0.001). Severity of itch correlated positively with HADS, stigmatization scale, and GAD-7. Itch in RTR was associated with higher incidence of depression assessed with BDI (OR 3.7). Moreover, higher prevalence of anxiety was found among patients suffering from CKD-aI, assessed with HADS A and GAD-7 (OR 2.7 and OR 4.8, respectively) The results of our study clearly demonstrate that itch among RTR is a significant burden. Higher prevalence of depression and anxiety in this groups indicate the necessity of addressing itch relief as a part of holistic approach to patients after renal transplantation.

Chronic Intractable Pruritus in Chronic Kidney Disease Patients: Prevalence, Impact, and Management Challenges - A Narrative Review

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.

Chronic Kidney Disease-Associated Itch (CKD-aI) in Children-A Narrative Review

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.

Clinical Characteristics of Itch in Renal Transplant Recipients

Background: Chronic itch is the most common symptom in dermatology. End-stage renal disease-associated chronic itch (ESRDCI) is a common burden affecting up to 35% of patients treated with hemodialysis. Kidney transplant (KTx) is believed to be the best renal replacement therapy leading to the elimination of ESRDCI. The study was undertaken to characterize and assess the prevalence of itch among patients after renal transplantation.

Methods: Between October 2019 and January 2020, we analyzed the data of 197 patients comprising 121 males (61.4%) and 76 females (38.6%) and aged 54.5 ± 13.6 years. The data collection was performed with a specially designed questionnaire. Level of itch after renal transplantation was assessed with the use of a Numeral Rating Scale, a Visual Rating Scale, and 4-Item Itch Questionnaire. Moreover, the previous 3 days of itching were evaluated.

Results: The patients suffered from chronic renal disease for 20.2 ± 12.3 years, with a mean time of pre-transplant dialysis of 2.6 ± 2.4 years and a mean time after the KTx of 8.0 ± 6.5 years. The itch was present in 38.6% of the patients during the hemodialysis, and in 73.7% of cases, the itch ceased completely after the successful transplantation. Moreover, only 2.63% of the cases had no improvement. Nevertheless, the itch was reported in 42 (21.3%) renal transplant recipients (RTR), and in 22 (52.4%) cases, the itch appeared after transplantation. The majority of patients suffering from itch were women (54.8%). Itch in the last 3 days was reported in 21 patients. The itch's severity was assessed with a numerical rating scale (NRS), with the worst severity measured at 6 ± 2.2 points indicating moderate itch. In most cases (57.1%), itch affected multiple body areas. Extremities (50%) and the back (50%) were among the most frequently affected areas. The sensation had a mostly short duration and was most frequently reported in the evening. Only eight patients suffered for the whole day. Hot water was the most frequently reported (16.7%) alleviating factor, whilst sweat was responsible for itch aggravation in 35.9% of cases.

Conclusion: Our analysis on representative patients' population indicates that itch after KTx is an important problem. Moreover, it is worth noting that more than half of the RTR did not suffer from itch during dialysis.