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Pathogenesis and Treatment of Pruritus Associated with Chronic Kidney Disease and Cholestasis. Int J Mol Sci 2023; 24:ijms24021559. [PMID: 36675074 PMCID: PMC9864517 DOI: 10.3390/ijms24021559] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/07/2023] [Accepted: 01/11/2023] [Indexed: 01/14/2023] Open
Abstract
Itching is an unpleasant sensation that provokes the desire to scratch. In general, itching is caused by dermatologic diseases, but it can also be caused by systemic diseases. Since itching hampers patients' quality of life, it is important to understand the appropriate treatment and pathophysiology of pruritus caused by systemic diseases to improve the quality of life. Mechanisms are being studied through animal or human studies, and various treatments are being tested through clinical trials. We report current trends of two major systemic diseases: chronic kidney disease and cholestatic liver disease. This review summarizes the causes and pathophysiology of systemic diseases with pruritus and appropriate treatments. This article will contribute to patients' quality of life. Further research will help understand the mechanisms and develop new strategies in the future.
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Abdallah AM, Elsheikh SM, ElBarbary RA. Prevalence and determinants of severity of uremic pruritus in hemodialysis patients: a multicentric study. J Investig Med 2023; 71:42-46. [PMID: 36191944 DOI: 10.1136/jim-2022-002360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2022] [Indexed: 01/21/2023]
Abstract
Uremic pruritus (UP) is a common and distressing symptom in patients with advanced or end-stage renal disease under hemodialysis (HD). The present multicentric study aimed to identify prevalence and determinants of severity of UP among Egyptian patients. Performed investigations included serum urea, creatinine, calcium, phosphorus, parathormone, ferritin and liver enzymes. Pruritus was evaluated using the visual analog scale. The study included 295 patients on maintenance HD. They comprised 151 patients (51.2%) with UP. Independent predictors of UP included associated hypertension (OR: 0.48, 95% CI 0.28 to 0.83, p=0.008), higher calcium levels (OR: 1.29, 95% CI 1.02 to 1.62, p=0.032), higher phosphorus levels (OR: 1.18, 95% CI 1.02 to 1.37, p=0.03) and higher high-sensitivity C-reactive protein (hsCRP) levels (OR: 1.0, 95% CI 1.0 to 1.01, p=0.049). Independent predictors of significant UP included longer HD duration (OR: 1.23, 95% CI 1.1 to 1.38, p<0.001), lack of vitamin D supplementation (OR: 3.71, 95% CI 1.03 to 13.4, p=0.045), lower albumin levels (OR: 0.32, 95% CI 0.14 to 0.74, p=0.008) and higher hsCRP levels (OR (CRP): 1.02 (1.0-1.03), p=0.011). In conclusion, UP is fairly common among Egyptian HD patients. Independent predictors of UP severity include longer HD duration, lack of vitamin D supplementation, lower albumin levels and higher hsCRP levels.
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Affiliation(s)
| | - Samaa M Elsheikh
- Dermatology Department, Alexandria University, Alexandria, Egypt
| | - Rasha A ElBarbary
- Dermatology and Venereology Department, Al-Azhar University, Cairo, Egypt
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Gurnani P, Miloh T, Chandar J, Landau DA, Hajjar F, Yosipovitch G. Systemic causes of non-dermatologic chronic pruritus in the pediatric population and their management: An unexplored area. Pediatr Dermatol 2021; 38:1051-1060. [PMID: 34515372 DOI: 10.1111/pde.14596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chronic pruritus associated with systemic diseases in the pediatric population has been infrequently addressed in the literature. This review focuses on chronic pruritus presenting without cutaneous manifestations. Common systemic etiologies include diseases with hepatic, renal, and hematologic origins. This encompasses several congenital liver disorders, end-stage renal disease (ESRD), and lymphoproliferative disorders such as Hodgkin's lymphoma. In this paper, an expert panel describes the clinical characteristics, pathophysiology, and therapeutic treatment ladders for chronic pruritus associated with the aforementioned systemic etiologies. Novel therapies are also reviewed. Our aim is to shed light on this unexplored area of pediatric dermatology and instigate further research.
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Affiliation(s)
- Pooja Gurnani
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery & Miami Itch Center, University of Miami, Miller School of Medicine, Miami, FL, USA.,Florida International University, Herbert Wertheim College of Medicine, Miami, FL, USA
| | - Tamir Miloh
- Pediatric Transplant Hepatology, Miami Transplant Institute, Jackson Health System, Miami, FL, USA
| | - Jayanthi Chandar
- Pediatric Kidney Transplantation, Miami Transplant Institute, Jackson Health System, Miami, FL, USA
| | | | - Fouad Hajjar
- AdventHealth For Children Pediatric Oncology and Hematology, Orlando, FL, USA
| | - Gil Yosipovitch
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery & Miami Itch Center, University of Miami, Miller School of Medicine, Miami, FL, USA
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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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Rehman IU, Ahmed R, Rahman AU, Wu DBC, Munib S, Shah Y, Khan NA, Rehman AU, Lee LH, Chan KG, Khan TM. Effectiveness and safety profiling of zolpidem and acupressure in CKD associated pruritus: An interventional study. Medicine (Baltimore) 2021; 100:e25995. [PMID: 34032717 PMCID: PMC8154401 DOI: 10.1097/md.0000000000025995] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 04/28/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Chronic kidney disease (CKD)-associated pruritus (CKD-aP) contributes to poor quality of life, including reduced sleep quality and poor sleep quality is a source of patient stress and is linked to lower health-related quality of life. This study aimed to investigate the effectiveness of zolpidem 10 mg and acupressure therapy on foot acupoints to improve the sleep quality and overall quality of life among hemodialysis patients suffering from CKD-aP. METHOD A multicenter, prospective, randomized, parallel-design, open label interventional study to estimate the effectiveness of zolpidem (10 mg) oral tablets versus acupressure on sleep quality and quality of life in patients with CKD-aP on hemodialysis. A total of 58 hemodialysis patients having sleep disturbance due to CKD-aP completed the entire 8-week follow-up. The patients were divided into a control (acupressure) group of 28 patients and an intervention (zolpidem) group of 30 patients. RESULTS A total of 58 patients having CKD-aP and sleep disturbance were recruited. In the control group there was a reduction in the PSQI score with a mean ± SD from 12.28 ± 3.59 to 9.25 ± 3.99, while in the intervention group the reduction in PSQI score with a mean ± SD was from 14.73 ± 4.14 to 10.03 ± 4.04 from baseline to endpoint. However, the EQ5D index score and EQ-visual analogue scale (VAS) at baseline for the control group with a mean ± SD was 0.49 ± 0.30 and 50.17 ± 8.65, respectively, while for the intervention group the values were 0.62 ± 0.26 and 47.17 ± 5.82, respectively. The mean EQ5D index score in the control group improved from 0.49 ± 0.30 to 0.53 ± 0.30, but in the intervention group there was no statistical improvement in mean EQ5D index score from 0.62 ± 0.26 to 0.62 ± 0.27 from baseline to week 8. The EQ 5D improved in both groups and the EQ-VAS score was 2.67 points higher at week 8 as compared to baseline in the control group, while in the intervention group the score was 3.33 points higher at week 8 as compared to baseline. Comparing with baseline, the PSQI scores were significantly reduced after week 4 and week 8 (P = < .001). Furthermore, at the end of the study, the PSQI scores were significantly higher in the control as compared to the intervention group (P = .012). CONCLUSION An improvement in sleep quality and quality of life among CKD-aP patients on hemodialysis has been observed in both the control and intervention groups. Zolpidem and acupressure safety profiling showed no severe adverse effect other that drowsiness, nausea and daytime sleeping already reported in literature of zolpidem.
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Affiliation(s)
- Inayat Ur Rehman
- School of Pharmacy, Monash University, Jalan Lagoon Selatan, Bandar Sunway, Selangor Darul Ehsan, Malaysia
- Department of Pharmacy, Abdul Wali Khan University, Mardan, Khyber Pukhtoonkhwa
| | - Raheel Ahmed
- Department of Nephrology, Institute of Kidney Diseases, Peshawar
| | | | - David Bin Chia Wu
- School of Pharmacy, Monash University, Jalan Lagoon Selatan, Bandar Sunway, Selangor Darul Ehsan, Malaysia
| | - Syed Munib
- Department of Nephrology, Institute of Kidney Diseases, Peshawar
| | - Yasar Shah
- Department of Pharmacy, Abdul Wali Khan University, Mardan, Khyber Pukhtoonkhwa
| | - Nisar Ahmad Khan
- Department of Nephrology, North West General Hospital and Research Center, Peshawar
| | - Ateeq Ur Rehman
- Biomedical Engineering Technology, Foundation University Islamabad, 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, Bandar Sunway 47500, Selangor Darul Ehsan, Malaysia
| | - Kok Gan Chan
- International Genome Centre, Jiangsu University, Zhenjiang, China
- ISB (Genetics), Faculty of Science, University of Malaya, Kuala Lumpur, Malaysia
| | - Tahir Mehmood Khan
- School of Pharmacy, Monash University, Jalan Lagoon Selatan, Bandar Sunway, Selangor Darul Ehsan, Malaysia
- Institute of Pharmaceutical Sciences, University of Veterinary and Animal Science, Outfall Campus, Civil Lines, Lahore, Pakistan
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Xie Q, Hu N, Chen Y. Chronic kidney disease-associated pruritus significantly impacts on quality of life of patients on haemodialysis and associates with increased levels of serum calcium and phosphorus. Postgrad Med J 2021; 98:e16. [PMID: 37066508 DOI: 10.1136/postgradmedj-2020-139688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/09/2021] [Accepted: 03/24/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE OF THE STUDY Chronic kidney disease-associated pruritus (CKD-aP) is common among patients on maintenance haemodialysis (HD). We performed a study to explore the clinical features of patients with CKD-aP and evaluate the impact of CKD-aP on the quality of life of HD patients. STUDY DESIGN Patients who were receiving regular HD over 3 months were recruited. Quality of life was quantified by the Short Form-12 (SF-12) questionnaire. Pruritus was evaluated by the 5D-Itch Scale. Demographic characteristics and biochemical indicators were obtained from the medical record system. Multiple linear regression was used to assess the association between pruritus and targeting factors. The relationship between the scores on the 5D-Itch Scale and SF-12 was analysed using multiple linear regression, adjusted for other factors, to demonstrate the impact of CKD-aP on the quality of life of HD patients. RESULTS In total, 269 out of 301 (89.4%) patients accomplished all investigations. The prevalence of CKD-aP in our cohort was 40.9%. Age (B=0.339, p=0.042), treatment with haemoperfusion (B=1.853, p=0.018), and serum level of calcium (B=3.566, p=0.008) and phosphorus (B=1.543, p=0.002) were independently associated with pruritus. Score on the 5D-Itch Scale negatively impacted on physical component summary (B=-0.778, p<0.001) and mental component summary (B=-0.675, p<0.001). CONCLUSIONS Pruritus significantly aggravates the quality of life of HD patients. Irregularity in the metabolism of calcium and phosphorus may partially explain the mechanism of CKD-aP. More effective treatment of CKD-MBD may help to prevent pruritus and improve patients' mental and physical health conditions.
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Affiliation(s)
- Qiuyu Xie
- Renal Division,Department of internal medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
| | - Nan Hu
- Renal Division,Department of internal medicine, Peking University First Hospital, Beijing, China .,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
| | - Yuqing Chen
- Renal Division,Department of internal medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
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Sukul N, Karaboyas A, Csomor PA, Schaufler T, Wen W, Menzaghi F, Rayner HC, Hasegawa T, Al Salmi I, Al-Ghamdi SM, Guebre-Egziabher F, Ureña-Torres PA, Pisoni RL. Self-reported Pruritus and Clinical, Dialysis-Related, and Patient-Reported Outcomes in Hemodialysis Patients. Kidney Med 2021; 3:42-53.e1. [PMID: 33604539 PMCID: PMC7873756 DOI: 10.1016/j.xkme.2020.08.011] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
RATIONALE & OBJECTIVE Chronic kidney disease (CKD)-associated pruritus, generalized itching related to CKD, affects many aspects of hemodialysis patients' lives. However, information regarding the relationship between pruritus and several key outcomes in hemodialysis patients remains limited. STUDY DESIGN Prospective cohort. SETTING & PARTICIPANTS 23,264 hemodialysis patients from 21 countries in the Dialysis Outcomes and Practice Patterns Study (DOPPS) phases 4 to 6 (2009-2018). EXPOSURE Pruritus severity, based on self-reported degree to which patients were bothered by itchy skin (5-category ordinal scale from "not at all" to "extremely"). OUTCOMES Clinical, dialysis-related, and patient-reported outcomes. ANALYTICAL APPROACH Cox regression for time-to-event outcomes and modified Poisson regression for binary outcomes, adjusted for potential confounders. RESULTS The proportion of patients at least moderately bothered by pruritus was 37%, and 7% were extremely bothered. Compared with the reference group ("not at all"), the adjusted mortality HR for patients extremely bothered by pruritus was 1.24 (95% CI, 1.08-1.41). Rates of cardiovascular and infection-related deaths and hospitalizations were also higher for patients extremely versus not at all bothered by pruritus (HR range, 1.17-1.44). Patients extremely bothered by pruritus were also more likely to withdraw from dialysis and miss hemodialysis sessions and were less likely to be employed. Strong monotonic associations were observed between pruritus severity and longer recovery time from a hemodialysis session, lower physical and mental quality of life, increased depressive symptoms, and poorer sleep quality. LIMITATIONS Residual confounding, recall bias, nonresponse bias. CONCLUSIONS Our findings demonstrate how diverse and far-reaching poor outcomes are for patients who experience CKD-associated pruritus, specifically those with more severe pruritus. There is need for change in practice patterns internationally to effectively identify and treat patients with pruritus to reduce symptom burden and improve quality of life and possibly even survival.
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Affiliation(s)
- Nidhi Sukul
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- Division of Nephrology, Veterans Affairs Ann Arbor Health System, Ann Arbor, MI
| | | | | | | | | | | | - Hugh C. Rayner
- Department of Renal Medicine, University Hospitals Birmingham NHS FT, United Kingdom
| | - Takeshi Hasegawa
- Showa University Research Administration Center; Department of Hygiene, Public Health and Preventive Medicine, Graduate School of Medicine, Tokyo, Japan
- Division of Nephrology, Department of Medicine, School of Medicine, Showa University, Tokyo, Japan
| | - Issa Al Salmi
- Department of Renal Medicine, Royal Hospital, Muscat, Oman
| | - Saeed M.G. Al-Ghamdi
- Department of Medicine, College of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | | | - Pablo-Antonio Ureña-Torres
- Department of Dialysis, AURA Nord Saint Ouen, Paris, France
- Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
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Abstract
BACKGROUND Itch in patients with chronic kidney disease (CKD) is common, often very distressing and associated with depression, reduced quality of life, and increased death. The most common first-line treatment has been the use of antihistamines despite the lack of substantial evidence for its use for uraemic itch. Few recommendations and guidelines exist for treatment. OBJECTIVES We aimed to determine: 1) the benefits and harms (both absolute and relative) of all topical and systemic interventions for the treatment of uraemic itch, either alone or in combination, when compared with placebo or standard care; and, 2) the dose strength or frequency, stage of kidney disease or method of dialysis used (where applicable) in cases where the effects of these interventions vary depending on co-interventions. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 17 December 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) in adults with CKD stages 4 or 5 comparing treatments (pharmacological, topical, exposure, dialysis modality) for CKD associated itch to either placebo or other established treatments. DATA COLLECTION AND ANALYSIS Two authors independently abstracted study data and assessed study quality. Data were analysed using a random effects meta-analysis design estimating the relative effects of treatment versus placebo. Estimates of the relative effects between treatments are included where possible. For continuous measures of severity of itch up to three months, mean difference (MD) or standardised mean difference (SMD) were used. When reported, adverse effects were tabulated. The certainty of the evidence was estimated using GRADE. MAIN RESULTS Ninety-two RCTs, randomising 4466 participants were included. Fifty-eight studies (3285 participants) provided sufficient data to be meta-analysed. Of these, 30 compared an intervention to a placebo or control. The 10 cm Visual Analogue Scale (VAS) was the dominant instrument utilized for itch reporting and the Duo score was used in a minority of studies. GABA analogues including, gabapentin and pregabalin, reduce itch in patients with CKD (5 studies, 297 participants: 4.95 cm reduction, 95% CI 5.46 to 4.44 lower in VAS compared to placebo; high certainty evidence). Kappa opioid agonists, including nalfurafine also reduced itch in this population (6 studies, 661 participants: 1.05 cm reduction, 95% CI 1.40 to 0.71 lower in VAS compared to placebo; high certainty evidence). Ondansetron had little or no effect on itch scores (3 studies, 183 participants: 0.38 cm reduction, 95% CI 1.04 lower to 0.29 higher in VAS compared to placebo; high certainty evidence). Reduction in the severity of itch was reported with oral montelukast, turmeric, zinc sulfate and topical capsaicin. For all other interventions, the certainty of the evidence was low to moderate, and the interventions had uncertain effects on uraemic pruritus. Six studies have disclosed significant financial support from their respective manufacturers, six were affected by lack of blinding, and 11 studies have 15 participants or less. Older, smaller RCTs often failed to follow intention-to-treat protocols with unexplained dropouts after randomisation. Adverse effects were generally poorly and inconsistently reported across all RCTs. No severe adverse events were reported for any intervention. AUTHORS' CONCLUSIONS The RCTs of this meta-analysis contain a large array of interventions with a diverse set of comparators. For many interventions, trials are sparse. This served to make informative meta-analysis challenging. Of all treatments for uraemic pruritus, gabapentinoids (gabapentin and pregabalin) were the most studied and show the greatest reduction in itch scores. Further RCTs, even of the scale of the largest trials included in this review, are unlikely to significantly change this finding. Kappa-opioid agonists (mainly nalfurafine) also may reduce itch, but indirect comparison suggests a much more modest effect in comparison to GABA analogues. Evidence for oral montelukast, turmeric, zinc sulfate, and topical capsaicin also showed an itch score reduction. However, these reductions were reported in small studies, and warrant further investigation. Ondansetron did not reduce itch. It is somewhat unlikely that a further study of ondansetron will change this result.
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Affiliation(s)
- Daniel Hercz
- Jackson Memorial Hospital / University of Miami, Miami, FL, USA
| | - Simon H Jiang
- Department of Renal Medicine, Canberra Hospital, Garran, Australia
| | - Angela C Webster
- Centre for Transplant and Renal Research, Westmead Millennium Institute, The University of Sydney at Westmead, Westmead, Australia
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
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Ting SW, Fan PC, Lin YS, Lin MS, Lee CC, Kuo G, Chang CH. Uremic pruritus and long-term morbidities in the dialysis population. PLoS One 2020; 15:e0241088. [PMID: 33104746 PMCID: PMC7588085 DOI: 10.1371/journal.pone.0241088] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 10/07/2020] [Indexed: 12/11/2022] Open
Abstract
Background Uremic pruritus (UP) is a multifactorial problem that contributes to low quality of life in dialysis patients. The long-term influences of UP on dialysis patients are still poorly understood. This study aims to elucidate the contribution of UP to long-term outcomes. Materials and method We used the Taiwan National Health Insurance Research Database to conduct this study. Patients on chronic dialysis were included and divided into UP and non-UP groups according to the long-term prescription of antihistamine in the absence of other indications. The outcomes include infection-related hospitalization, catheter-related infection, major adverse cardiac and cerebrovascular events (MACCE) and parathyroidectomy. Results After propensity score matching, 14,760 patients with UP and 29,520 patients without UP were eligible for analysis. After a mean follow-up of 5 years, we found that infection-related hospitalization, MACCE, catheter-related infection, heart failure and parathyroidectomy were all slightly higher in the UP than non-UP group (hazard ratio: 1.18 [1.16–1.21], 1.05 [1.01–1.09], 1.16 [1.12–1.21], 1.08 [1.01–1.16] and 1.10 [1.01–1.20], respectively). Subgroup analysis revealed that the increased risk of adverse events by UP was generally more apparent in younger patients and patients who underwent peritoneal dialysis. Conclusion UP may be significantly associated with an increased risk of long-term morbidities.
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Affiliation(s)
- Sze-Wen Ting
- Department of Dermatology, New Taipei City Tu-Cheng Municipal Hospital, New Taipei City (Built and Operated by Chang Gung Medical Foundation), Taoyuan, Taiwan
| | - Pei-Chun Fan
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yu-Sheng Lin
- Department of Cardiology, Chiayi Chang Gung Memorial Hospital, Puzi City, Taiwan
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Ming-Shyan Lin
- Department of Cardiology, Chiayi Chang Gung Memorial Hospital, Puzi City, Taiwan
| | - Cheng-Chia Lee
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - George Kuo
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chih-Hsiang Chang
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
- * E-mail: ,
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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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Sadeghnejad Z, Karampourian A, Borzou SR, Gholyaf M, Mohammadi Y, Hadadi R. The Effect of Ostrich Oil as a Complementary Medicine on the Severity of Pruritus and Quality of Life in Hemodialysis Patients. Complement Med Res 2020; 28:40-45. [PMID: 32659768 DOI: 10.1159/000508288] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/28/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Pruritus is one of the most common problems in a uremic syndrome that reduces the quality of life due to the constant unpleasant feeling. The purpose of this study was to investigate the effect of ostrich oil massage on the severity of pruritus and quality of life in hemodialysis patients. METHODS In this study, 68 hemodialysis patients with pruritus were selected based on the available sampling method. The intervention group used 1 mL ostrich oil on the pruritus area for 10 min each night for 1 month. The control group received a placebo massage. Pruritus severity questionnaire-based itch severity scale and quality of life questionnaire were completed, respectively, at the end of each week and at the end of the period. Statistical analysis was done using SPSS software version 23 and applying on independent t test, paired t test, and analysis of covariance. RESULTS During the first and second weeks after the treatment, there was no statistical difference between the mean scores of pruritus severity in both groups (p > 0.05); however, in the third and fourth weeks after the treatment, the mean severity level of pruritus in the ostrich oil group was lower than in the placebo group, and these differences were statistically significant between the two groups (p < 0.05). There was no significant difference in quality of life between two groups of ostrich and placebo. CONCLUSION The use of ostrich oil was effective in reducing pruritus in hemodialysis patients. This method can be proposed as a complementary method for relieving pruritus in hemodialysis patients.
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Affiliation(s)
- Zahra Sadeghnejad
- School of Nursing and Midwifery, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Arezou Karampourian
- Urology and Nephrology Research Center, Department of Nursing, School of Nursing and Midwifery, Hamadan University of Medical Sciences, Hamadan, Iran,
| | - Seyed Reza Borzou
- Urology and Nephrology Research Center, Department of Nursing, School of Nursing and Midwifery, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Mahmoud Gholyaf
- Department of Nephrology, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Younes Mohammadi
- Department of Epidemiology, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Rasoul Hadadi
- Department of Pharmacology and Toxicology, School of Pharmacy, Hamadan University of Medical Sciences, Hamadan, Iran
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Nair D, Finkelstein FO. Pruritus as a Patient-Reported Primary Trial End Point in Hemodialysis: Evaluation and Implications. Am J Kidney Dis 2020; 76:148-151. [PMID: 32334827 DOI: 10.1053/j.ajkd.2020.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 01/19/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Devika Nair
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Center for Kidney Disease, Nashville, TN
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Golpanian RS, Kim HS, Yosipovitch G. Effects of Stress on Itch. Clin Ther 2020; 42:745-756. [PMID: 32147148 DOI: 10.1016/j.clinthera.2020.01.025] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/25/2020] [Accepted: 01/28/2020] [Indexed: 01/21/2023]
Abstract
PURPOSE Psychological stress and ensuing modulation of the immune and nervous systems can have a significant impact on itch. Stress can exacerbate itch and vice versa, resulting in a vicious cycle that can greatly impair a patient's quality of life. This review summarizes the association between stress and itch, elucidates the mechanism by which these two phenomena influence one another, and explores treatment modalities that aim to reduce stress-induced itch. METHODS A complete search of the PubMed and Google Scholar databases was completed and literature pertinent to this review was compiled. FINDINGS Both acute and chronic stress can significantly affect itch in healthy individuals and in those diagnosed with itchy skin diseases as well as systemic diseases, thus resulting in a vicious cycle in which stress exacerbates itch and vice versa. The mechanisms by which stress induces or aggravates itch include both central and peripheral activation of the hypothalamic-pituitary-adrenal axis and sympathetic nervous system. Activation of these systems, in turn, affects the mast cells, keratinocytes, and nerves that secrete neuropeptides, such as substance P, nerve growth factor, acetylcholine, histamine, and itchy cytokines. A dysfunctional parasympathetic response is thought to be involved in the chronic stress/itch response. Brain structures associated with emotion, such as the limbic system and periaqueductal gray, which work on the descending facilitation of itch, play a significant role in stress-induced itch. IMPLICATIONS As specific brain structures are associated with stress, drug treatments targeting these areas (ie, γ-aminobutyric acid-ergic drugs, serotonin and norepinephrine reuptake inhibitors) may help to modulate itch. Stress can also be combatted using nonpharmacologic treatments such as cognitive-behavioral therapies and stress-relieving holistic approaches (eg, yoga, acupuncture).
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Affiliation(s)
- Rachel Shireen Golpanian
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, Itch Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Hei Sung Kim
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, Itch Center, University of Miami Miller School of Medicine, Miami, FL, USA; Department of Dermatology, Incheon St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Gil Yosipovitch
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, Itch Center, University of Miami Miller School of Medicine, Miami, FL, USA.
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Minato S, Hirai K, Morino J, Kaneko S, Yanai K, Mutsuyoshi Y, Ishii H, Matsuyama M, Kitano T, Shindo M, Aomatsu A, Miyazawa H, Ito K, Ueda Y, Hoshino T, Ookawara S, Morishita Y. Factors Associated with Uremic Pruritus in Patients Undergoing Peritoneal Dialysis. Int J Nephrol Renovasc Dis 2020; 13:1-9. [PMID: 32021382 PMCID: PMC6969704 DOI: 10.2147/ijnrd.s224871] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 12/21/2019] [Indexed: 11/23/2022] Open
Abstract
Aim The aim of this study was to investigate different intensities of uremic pruritus in the daytime and nighttime, as well as contributing factors, in patients undergoing peritoneal dialysis (PD). Methods A total of 46 patients (31 males, 15 females) with a mean age of 59.4±14.7 years and mean PD vintage of 29.2±25.2 months were enrolled in this single-center, prospective, cross-sectional study. The intensity of uremic pruritus in the daytime and nighttime was assessed using a visual analog scale (VAS). The relationships between intensity and various clinical and laboratory parameters were analyzed using multiple linear regression analyses. Results The most common site of uremic pruritus was on the back (70%), followed by lower limbs (67%), chest and abdomen (59%), upper limbs (28%), and head and neck (22%). Mean VAS scores were higher in the nighttime compared with the daytime (4.5±3.3 vs. 3.5±2.7, P=0.02). Only male sex was correlated with higher uremic pruritus intensity in the daytime (standard coefficient [β]=0.310, P=0.036). PD vintage (β=0.415, P=0.004) and topical medicines, including moisturizer and topical corticosteroid use (β=0.345, P=0.019), were independently correlated with higher uremic pruritus intensity in the nighttime. Conclusion Uremic pruritus intensity was greater in the nighttime than in the daytime in PD patients. Male sex was associated with higher uremic pruritus intensity in the daytime, whereas PD vintage and topical medicine use were associated with higher uremic pruritus intensity in the nighttime.
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Affiliation(s)
- Saori Minato
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Keiji Hirai
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Junki Morino
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Shohei Kaneko
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Katsunori Yanai
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yuko Mutsuyoshi
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hiroki Ishii
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Momoko Matsuyama
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Taisuke Kitano
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Mitsutoshi Shindo
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Akinori Aomatsu
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Haruhisa Miyazawa
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kiyonori Ito
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yuichiro Ueda
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Taro Hoshino
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Susumu Ookawara
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yoshiyuki Morishita
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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Swarna SS, Aziz K, Zubair T, Qadir N, Khan M. Pruritus Associated With Chronic Kidney Disease: A Comprehensive Literature Review. Cureus 2019; 11:e5256. [PMID: 31572641 PMCID: PMC6760874 DOI: 10.7759/cureus.5256] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The prevalence of pruritus in chronic kidney disease (CKD) patients has varied over the years, and some studies suggest the prevalence may be coming down with more effective dialysis. Chronic kidney disease-associated pruritus (CKD-aP), previously called uremic pruritus, is a distressing symptom experienced by patients with mainly advanced chronic kidney disease. CKD-aP is associated with poor quality of life, depression, anxiety, sleep disturbance, and increased mortality. The incidence of CKD-aP is decreasing given improvements in dialysis treatments, but approximately 40% of patients with end-stage renal disease experience CKD-aP. While the pathogenesis of CKD-aP is not well understood, the interaction between non-myelinated C fibers and dermal mast cells plays an important role in precipitation and sensory stimulation. Other causes of CKD-aP include metabolic abnormalities such as abnormal serum calcium, parathyroid, and phosphate levels; an imbalance in opiate receptors is also an important factor. CKD-aP usually presents as large symmetric reddened areas of skin, often at night. Managing CKD-aP is a challenge. Research in this area is difficult because most studies are not comparable given their small group samples, study designs, and lack of standardized study measures. The most commonly used treatment is a combination of narrow-band ultraviolet B phototherapy and a μ-opioid receptor antagonist such as naltrexone.
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Affiliation(s)
| | - Kashif Aziz
- Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Tayyaba Zubair
- Internal Medicine, Desai Medical Center, Ellicott City, MD, USA
| | - Nida Qadir
- Internal Medicine, Liaquat University of Medical and Health Sciences, Liaquat University Hospital Jamshoro, Hyderabad, PAK
| | - Mehreen Khan
- Internal Medicine, George Washington University School of Medicine and Health Sciences, Washington DC, USA
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Sorour NE, Elesawy FM, Tabl HA, Ibrahim ME, Akl EM. Evaluation of serum levels of neurotrophin 4 and brain-derived nerve growth factor in uremic pruritus patients. Clin Cosmet Investig Dermatol 2019; 12:109-114. [PMID: 30799944 PMCID: PMC6371925 DOI: 10.2147/ccid.s190917] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Pruritus is a common symptom in end-stage renal failure. Many patients suffer from this severe distressing symptom. Although several factors have been postulated to explain uremic pruritus, there is not any conclusive evidence for one of these factors. Objectives We aimed to evaluate serum levels of brain-derived nerve growth factor (BDNF), neurotrophin-4 (NT-4), serum calcium, phosphors and parathyroid hormone in uremic patients with pruritus and without pruritus compared to control subjects. Methods One hundred twenty patients suffering from renal failure and 60 healthy subjects were included in the study. Serum BDNF and NT4 levels were determined by ELISA. The serum calcium, phosphorus, parathyroid hormone and hemoglobin were also evaluated. Results Serum BDNF was significantly higher in uremic patients with pruritus (P=0.0026) and uremic patients without pruritus (P=0.0294) than control subjects. In addition, NT-4 levels were significantly elevated in uremic patients with pruritus (P<0.0001) and uremic patients without pruritus than control subjects (P=0.0016). There was no significant difference of serum level of BDNF between uremic patients with pruritus and uremic patients without pruritus (P=0.1215). However, serum NT-4 was higher in uremic patients with pruritus vs nonpruritic uremic patients with a significant difference (P=0.0026). There was a positive significant correlation between serum level of NT-4 and severity of pruritus (P=0.024). Conclusion The present study shows that NT-4 level is increased in the serum of uremic patients with pruritus and there was a significant correlation between NT-4 and severity of pruritus suggesting that NT-4 may have a role in uremic pruritus.
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Affiliation(s)
- Neveen E Sorour
- Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Benha University, Benha, Egypt,
| | - Fatma M Elesawy
- Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Benha University, Benha, Egypt,
| | - Hala A Tabl
- Department of Microbiology and Immunology, Faculty of Medicine, Benha University, Benha, Egypt
| | - Mohammed E Ibrahim
- Department of Internal Medicine, Faculty of Medicine, Benha University, Benha, Egypt
| | - Essam M Akl
- Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Benha University, Benha, Egypt,
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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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Phan FA, Srilestari A, Mihardja H, Marbun MBH. Effects of acupuncture on uremic pruritus in patients undergoing hemodialysis. ACTA ACUST UNITED AC 2018. [DOI: 10.1088/1742-6596/1073/6/062049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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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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Risk of Skin Diseases in Maintenance Hemodialysis. Transplant Proc 2018; 50:1616-1620. [PMID: 30056869 DOI: 10.1016/j.transproceed.2018.02.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 02/19/2018] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Maintenance hemodialysis (HD) patients are potential transplant recipients. One of the most common cancers in the population of kidney recipients is skin neoplasm. Skin infections are also of a particular importance. In this population, especially in patients on the transplant waiting list, full dermatological examination, including dermatoscopy, should be carried out routinely. MATERIALS AND METHODS The research was comprised of 105 HD patients (57 men, 48 women) with a mean age of 60.8 (range 25-94) years. The patients' skin condition was assessed and a dermatoscopic examination was performed. We compared the incidence of skin diseases in the two subpopulations: HD patients (n = 89) and HD patients active on the transplant waiting list (n = 16). RESULTS Bacterial, fungal, and viral infections in the group of HD patients occurred in 24.7%, 14.6%, and 6.7% of patients, respectively. In HD patients on the waiting list, bacterial skin diseases were reported in 12.5% of patients, and neither fungal nor viral infections were noticed. Malignant skin lesions and precancerous conditions, such as basal cell carcinoma and keratosis actinic, developed in 4.5% and 3.4% of the HD patients. These malignancies did not occur in HD patients on the waiting list. The results show proper qualification for transplantation in maintenance HD patients before the waiting list. In the group of dialysis patients, 67.4% required dermatological care, while in the HD waiting group only 12.5% required dermatological care. CONCLUSIONS The presented results prove the necessity of performing dermatological examinations on HD patients. Some dermatological skin lesions, if not diagnosed and treated, could progress to cancer after organ transplantation.
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The vicious cycle of itch and anxiety. Neurosci Biobehav Rev 2018; 87:17-26. [PMID: 29374516 DOI: 10.1016/j.neubiorev.2018.01.009] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 12/28/2017] [Accepted: 01/21/2018] [Indexed: 12/21/2022]
Abstract
Chronic itch is associated with increased stress, anxiety, and other mood disorders. In turn, stress and anxiety exacerbate itch, leading to a vicious cycle that affects patient behavior (scratching) and worsens disease prognosis and quality of life. This cycle persists across chronic itch conditions of different etiologies and even to some extent in healthy individuals, suggesting that the final common pathway for itch processing (the central nervous system) plays a major role in the relationship between itch and anxiety. Pharmacological and nonpharmacological treatments that reduce anxiety have shown promising anti-itch effects. Further research is needed to establish specific central mechanisms of the itch-anxiety cycle and provide new targets for treatment.
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Nakamoto H, Oh T, Shimamura M, Iida E, Moritake S. Nalfurafine hydrochloride for refractory pruritus in peritoneal dialysis patients: a phase III, multi-institutional, non-controlled, open-label trial. RENAL REPLACEMENT THERAPY 2017. [DOI: 10.1186/s41100-017-0133-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Li WH, Yin YM, Chen H, Wang XD, Yun H, Li H, Luo J, Wang JW. Curative effect of neutral macroporous resin hemoperfusion on treating hemodialysis patients with refractory uremic pruritus. Medicine (Baltimore) 2017; 96:e6160. [PMID: 28328802 PMCID: PMC5371439 DOI: 10.1097/md.0000000000006160] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 01/03/2017] [Accepted: 01/26/2017] [Indexed: 11/26/2022] Open
Abstract
This study aims to investigate the efficacy and safety of neutral macroporous resin hemoperfusion in treating maintenance hemodialysis (MHD) patients with refractory uremic pruritus (RUP).Ninety patients were enrolled and were randomly divided into 3 groups: control group, experiment 1 group, and experiment 2 group. Clinical symptom scores of skin itching were recorded before and at 4 and 8 weeks after the treatment. In addition, serum parathyroid hormone (PTH), calcium (Ca), phosphorus (P), and C-reactive protein (CRP) were detected; and the calcium-phosphorus product ([Ca] × [P]) was calculated to compare the curative effect.VSA score, modified Duo pruritus score, and CRP: these indices decreased to some extent at 4 and 8 weeks after treatment in the 2 experiment groups, compared with pretreatment (P < 0.05); and differences among these 3 groups were statistically significant (P < 0.05). PTH, P, and [Ca] × [P]: these indices decreased to some extent at 4 and 8 weeks after treatment in the 2 experiment groups, compared with pretreatment (P < 0.05); and differences between the control and experiment 1 groups, as well as between the control and experiment 2 groups, were statistically significant (P < 0.05). However, the difference between the experiment 1 and experiment 2 groups were not statistically significant (P < 0.05).The effects of HA330 and HA130 resin hemoperfusion apparatus on secondary hyperparathyroidism and the disorder of calcium and phosphorus metabolism are similar. The mechanism may be related to its strong adsorption effect, and its capacity to widely remove inflammatory mediators, immune mediators, and endotoxins.
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26
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Liaveri PG, Dikeos D, Ilias I, Lygkoni EP, Boletis IN, Skalioti C, Paparrigopoulos T. Quality of sleep in renal transplant recipients and patients on hemodialysis. J Psychosom Res 2017; 93:96-101. [PMID: 28107900 DOI: 10.1016/j.jpsychores.2016.12.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 11/22/2016] [Accepted: 12/23/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Sleep disorders are very common in patients with chronic kidney disease and they may not always subside after kidney transplantation. AIM AND METHODS The aim of this cross-sectional study was to evaluate the self-reported quality of sleep, insomnia problems in particular, and examine the factors that disturb sleep of kidney transplant recipients (KTx: n=152) in comparison to age- and sex-matched patients on dialysis (HD: n=67) and participants with normal renal function (NOR: n=49), through the administration of the Athens Insomnia Scale (AIS) at least six months after transplantation. Clinical and laboratory data, as well as health-related quality of life, depression, anxiety, post-traumatic stress symptoms, and the presence of restless legs syndrome (RLS) and pruritus were investigated in relation to sleep problems. RESULTS The highest mean AIS score was observed in the transplant patients (KTx: 4.6±13.3 vs. HD: 3.8±8.1 vs. NOR: 2.4±10.2); both KTx and HD patients had a lower quality of sleep compared to participants with normal renal function. Multiple linear regression analysis showed that the determinants of the total AIS score were the frequency of post-traumatic stress symptoms, depression, RLS, diastolic blood pressure, and pain (all p<0.0001). CONCLUSION Although amelioration of renal function post-transplantation improves several aspects of quality of life, it does not seem to have a beneficial effect on self-reported sleep.
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Affiliation(s)
| | - Dimitris Dikeos
- Sleep Research Unit, First Department of Psychiatry, National and Kapodistrian University of Athens, Medical School, "Eginition" Hospital, Athens, Greece
| | - Ioannis Ilias
- Endocrine Unit, "Elena Venizelou" Hospital, Athens, Greece
| | - Eirini P Lygkoni
- School of Applied Mathematics and Physical Science, National Technical University of Athens, Athens, Greece
| | - Ioannis N Boletis
- Nephrology Department, Renal Transplantation Unit, "Laikon" Hospital, Athens, Greece
| | - Chryssanthi Skalioti
- Nephrology Department, Renal Transplantation Unit, "Laikon" Hospital, Athens, Greece
| | - Thomas Paparrigopoulos
- Sleep Research Unit, First Department of Psychiatry, National and Kapodistrian University of Athens, Medical School, "Eginition" Hospital, Athens, Greece
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Panahi Y, Dashti-Khavidaki S, Farnood F, Noshad H, Lotfi M, Gharekhani A. Therapeutic Effects of Omega-3 Fatty Acids on Chronic Kidney Disease-Associated Pruritus: a Literature Review. Adv Pharm Bull 2016; 6:509-514. [PMID: 28101457 PMCID: PMC5241408 DOI: 10.15171/apb.2016.064] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 09/20/2016] [Accepted: 10/24/2016] [Indexed: 12/31/2022] Open
Abstract
Uremic pruritus remains one of the most tormenting, frequent and potentially disabling problem in chronic kidney disease (CKD) patients. However, an area of substantial etiological interest with relation to uremic pruritus is the essential fatty acids deficiency. So we performed a literature review to elucidate the efficacy of omega-3 fatty acids on uremic pruritus. This review evaluated all of the studies published in English language, focusing on the clinical effects of omega-3 fatty acids on uremic pruritus. The literature review was conducted in December 2015 and carried out by searching Scopus, Medline, Cochrane central register of controlled trials, and Cochrane database of systematic reviews. The search terms were "kidney injury", "kidney failure", "chronic kidney disease", "end-stage renal disease", "dialysis", "hemodialysis", "peritoneal dialysis", "pruritus", "itch", "skin problems", "fish oil", "omega 3", "n-3 fatty acids", "polyunsaturated fatty acids", "docosahexaenoic acid", and "eicosapentaenoic acid". Four small studies investigating potential benefits of omega-3 fatty acids on symptoms of uremic pruritus were found. Among them, three small randomized controlled trials have shown a significant improvement in pruritus symptoms (evaluated by a standard questionnaire) in CKD patients who took omega-3 supplement compared to omega-6, omega-9, and placebo supplementation. Despite numerous limitations of the studies, it is worth noting that even minor reduction in itching symptoms may be clinically significant for CKD patients. Therefore, and considering multiple health benefits of omega-3 fatty acids in advanced CKD and negligible risk profile, omega-3 intake can wisely be applied to CKD patients with uremic pruritus.
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Affiliation(s)
- Yunes Panahi
- Chemical Injuries Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | | | - Farahnoosh Farnood
- Chronic Kidney Disease Research Center, Sina Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hamid Noshad
- Chronic Kidney Disease Research Center, Sina Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mahsa Lotfi
- Student Research Committee, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Afshin Gharekhani
- Drug Applied Research Center, Department of Clinical Pharmacy (Pharmacotherapy), Tabriz University of Medical Sciences, Tabriz, Iran
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28
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Sheu SL, Wang KC. Pruritus and Dermatitis in the Elderly. CURRENT GERIATRICS REPORTS 2016. [DOI: 10.1007/s13670-016-0189-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Khan TM, Wu DBC, Goh BH, Lee LH, Alhafez AA, Syed Sulaiman SA. An Observational Longitudinal Study Investigating the Effectiveness of 75 mg Pregabalin Post-Hemodialysis among Uremic Pruritus Patients. Sci Rep 2016; 6:36555. [PMID: 27824127 PMCID: PMC5099892 DOI: 10.1038/srep36555] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 10/18/2016] [Indexed: 11/09/2022] Open
Abstract
A prospective, observational, longitudinal study was conducted to assess the effectiveness of 75 mg pregabalin (PG) post-hemodialysis (pHD) for treatment-resistant uremic pruritus (UP). A total of forty-five patients completed the entire six week follow-up. At the baseline assessment, the majority of the patients were distressed by the UP frequency and intensity. Sleep (mean = 3.30 ± 1.1), leisure/social activities (mean = 2.90 ± 0.80) and distribution (mean = 2.92 ± 0.34) were the three domains that were primarily effected by the UP. Overall, further reduction in the 5D-itching scale (IS) was noted at day 42, which confirmed a sustained (B = -12.729, CI -13.257 to -12.201, p < 0.001) relief of pruritus severity among patients with treatment-resistant pruritus. Patients with a higher serum calcium level had a score difference of +1 from the other patients (B = 1.010, p = 0.061). There was a reduction of 12 points compared to the baseline 5D-IS for each patient on day 42 after using pregabalin 75 mg PD pHD for 42 days, which represented major relief. Among the demographic factors, only gender was significantly associated with the 5D-IS score.
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Affiliation(s)
- Tahir Mehmood Khan
- School of Pharmacy, Monash University, Bandar Sunway, Jalan Lagoon Selatan, 46700 Selangor, Malaysia.,College of Clinical Pharmacy, King Faisal University, Alahsa, Saudi Arabia
| | - David Bin-Chia Wu
- School of Pharmacy, Monash University, Bandar Sunway, Jalan Lagoon Selatan, 46700 Selangor, Malaysia
| | - Bey-Hing Goh
- School of Pharmacy, Monash University, Bandar Sunway, Jalan Lagoon Selatan, 46700 Selangor, Malaysia
| | - Learn-Han Lee
- School of Pharmacy, Monash University, Bandar Sunway, Jalan Lagoon Selatan, 46700 Selangor, Malaysia
| | - Abdul Aziz Alhafez
- Director and Senior consultant, Aljaber Kidney and Dialysis Center, Alahsa, Eastern Province, Saudi Arabia
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Abstract
Pruritus is a common and distressing symptom in patients with chronic kidney disease. The most recent epidemiologic data have suggested that approximately 40% of patients with end-stage renal disease experience moderate to severe pruritus and that uremic pruritus (UP) has a major clinical impact, being associated strongly with poor quality of life, impaired sleep, depression, and increased mortality. The pathogenesis of UP remains largely unclear, although several theories on etiologic or contributing factors have been proposed including increased systemic inflammation; abnormal serum parathyroid hormone, calcium, and phosphorus levels; an imbalance in opiate receptors; and a neuropathic process. UP can present somewhat variably, although it tends to affect large, discontinuous, but symmetric, areas of skin and to be most symptomatic at night. A variety of alternative systemic or dermatologic conditions should be considered, especially in patients with asymmetric pruritus or other atypical features. Treatment initially should focus on aggressive skin hydration, patient education on minimizing scratching, and optimization of the aspects of chronic kidney disease care that are most relevant to pruritus, including dialysis adequacy and serum parathyroid hormone, calcium, and phosphorus management. Data for therapy specifically for UP remain limited, although topical therapies, gabapentin, type B ultraviolet light phototherapy, acupuncture, and opioid-receptor modulators all may play a role.
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Affiliation(s)
- Sara A Combs
- Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - J Pedro Teixeira
- Department of Medicine, University of Washington Medical Center, University of Washington, Seattle, WA
| | - Michael J Germain
- Department of Medicine, Baystate Medical Center, Tufts University, Springfield, MA.
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31
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Wu HY, Peng YS, Chen HY, Tsai WC, Yang JY, Hsu SP, Pai MF, Lu HM, Chiang JF, Ko MJ, Wen SY, Chiu HC. A Comparison of Uremic Pruritus in Patients Receiving Peritoneal Dialysis and Hemodialysis. Medicine (Baltimore) 2016; 95:e2935. [PMID: 26945400 PMCID: PMC4782884 DOI: 10.1097/md.0000000000002935] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Uremic pruritus is common and bothersome in patients receiving either peritoneal dialysis (PD) or hemodialysis (HD). To date, the preferred dialysis modality regarding the alleviation of uremic pruritus remains controversial. We conducted this cross-sectional study to compare the prevalence, intensity, and characteristics of uremic pruritus between PD and HD patients. Patients receiving maintenance dialysis at a referral medical center in Taiwan were recruited. Dialysis modality, patient demographic, clinical characteristics, and laboratory data were recorded. The intensity of uremic pruritus was measured using visual analogue scale (VAS) scores. Multivariate linear regression analysis was conducted to compare the severity of uremic pruritus between PD and HD patients. Generalized additive models were applied to detect nonlinear effects between pruritus intensity and continuous covariates. A total of 380 patients completed this study, with a mean age of 60.3 years and 49.2% being female. Uremic pruritus was presented in 24 (28.6%) of the 84 PD patients and 113 (38.2%) of the 296 HD patients (P = .12). The VAS score of pruritus intensity was significantly lower among the PD patients than the HD patients (1.32 ± 2.46 vs 2.26 ± 3.30, P = .04). Multivariate linear regression analysis showed that PD was an independent predictor for lower VAS scores of pruritus intensity compared with HD (β-value -0.88, 95% confidence interval -1.62 to -0.13). The use of active vitamin D was also an independent predictor for a lower intensity of uremic pruritus, whereas hyperphosphatemia and higher serum levels of triglyceride and aspartate transaminase were significantly associated with higher pruritus intensity. There was a trend toward a less affected body surface area of uremic pruritus in the PD patients than in the HD patients, but the difference did not reach statistical significance (P = .13).In conclusion, the severity of uremic pruritus was lower among PD patients than HD patients, and PD may provide better alleviation of pruritus symptoms. The result provides a valuable reference for clinicians and patients when choosing a dialysis modality.
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Affiliation(s)
- Hon-Yen Wu
- From the Department of Internal Medicine (H-YW, Y-SP, H-YC, W-CT, J-YY, S-PH, M-FP); Department of Nursing (H-ML, J-FC), Far Eastern Memorial Hospital, New Taipei City, Taiwan; Department of Internal Medicine (H-YW, Y-SP, H-YC, J-YY, S-PH, M-FP); Department of Dermatology (M-JK, H-CC), National Taiwan University Hospital and College of Medicine; Institute of Epidemiology and Preventive Medicine, National Taiwan University (H-YW, W-CT); and Department of Dermatology (M-JK, S-YW), Taipei City Hospital, Taipei, Taiwan
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Weisshaar E, Weiss M, Passlick-Deetjen J, Tschulena U, Maleki K, Mettang T. Laboratory and dialysis characteristics in hemodialysis patients suffering from chronic itch--results from a representative cross-sectional study. BMC Nephrol 2015; 16:184. [PMID: 26530958 PMCID: PMC4632673 DOI: 10.1186/s12882-015-0177-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 10/22/2015] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND A representative cross-sectional study showed that chronic itch (lasting for a minimum of 6 weeks) affects 25.2 % (point prevalence) of hemodialysis (HD) patients. Pathophysiology and etiology of chronic itch (CI) in HD are still unclear. METHODS We investigated 860 HD patients from a representative randomly selected cluster-sample considering the regional distributions of dialysis units in Germany. The current analyses report comorbidities, laboratory values and dialysis characteristics of HD patients in relation to CI. RESULTS Diabetes was the only comorbidity that was associated with the occurrence of itch but interestingly with less CI. Except for creatinine, phosphorus, and parathormone, there were no significant associations between the occurrence and characteristics of CI and any laboratory value. Kt/V was not associated with the presence of CI. Patients dialyzed with polyarylethersulfone-membrane showed significantly more CI in all prevalence estimates and those dialyzed with polysulfone-membrane were significantly less affected by CI. CONCLUSIONS Long-term follow-up studies will show if the type of dialysis membrane influences the development of CI in HD patients. It is most likely that several factors e.g. elevated parathormone, origin of end stage renal disease (ESRD), type of dialysis membrane, and a neuropathic component all contribute to the occurrence of CI in HD patients. Future research should consider a multifactorial origin of itch in HD.
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Affiliation(s)
- Elke Weisshaar
- Department of Clinical Social Medicine, Occupational and Environmental Dermatology, University Hospital, Ruprecht Karls University, Thibautstrasse 3, 69115, Heidelberg, Germany.
| | - Melanie Weiss
- Department of Clinical Social Medicine, Occupational and Environmental Dermatology, University Hospital, Ruprecht Karls University, Thibautstrasse 3, 69115, Heidelberg, Germany.
| | | | | | - Klaudia Maleki
- Department of Clinical Social Medicine, Occupational and Environmental Dermatology, University Hospital, Ruprecht Karls University, Thibautstrasse 3, 69115, Heidelberg, Germany.
| | - Thomas Mettang
- Department of Nephrology, DKD Helios Clinic, Wiesbaden, Germany.
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Executive summary of the KDIGO Controversies Conference on Supportive Care in Chronic Kidney Disease: developing a roadmap to improving quality care. Kidney Int 2015; 88:447-59. [PMID: 25923985 DOI: 10.1038/ki.2015.110] [Citation(s) in RCA: 327] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 02/17/2015] [Accepted: 03/04/2015] [Indexed: 12/30/2022]
Abstract
Patients with advanced chronic kidney disease (CKD) have a high burden of physical and psychosocial symptoms, poor outcomes, and high costs of care. Current paradigms of care for this highly vulnerable population are variable, prognostic and assessment tools are limited, and quality of care, particularly regarding conservative and palliative care, is suboptimal. The KDIGO Controversies Conference on Supportive Care in CKD reviewed the current state of knowledge in order to define a roadmap to guide clinical and research activities focused on improving the outcomes of people living with advanced CKD, including those on dialysis. An international group of multidisciplinary experts in CKD, palliative care, methodology, economics, and education identified the key issues related to palliative care in this population. The conference led to a working plan to address outstanding issues in this arena, and this executive summary serves as an output to guide future work, including the development of globally applicable guidelines.
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Wang WY, Tarng DC, Chiang LC, Chu CM, Wang KY. Evaluation of uraemic pruritus in long-term dialysis patients using a modified Chinese scale. Nephrology (Carlton) 2015; 20:632-8. [PMID: 25917940 DOI: 10.1111/nep.12495] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2015] [Indexed: 01/06/2023]
Abstract
AIM To examine the reliability and validity of a modified Chinese version of the uraemic pruritus scale for measurement of different degrees of itching, as well as to identify the predictors for the severity of uraemic pruritus among long-term dialysis patients. METHODS Long-term dialysis patients (n = 110) were recruited for a cross-sectional study from a medical centre in Taiwan. A modified Chinese version of the uraemic pruritus scale was used to evaluate sleep disturbance and the severity, frequency and distribution of itching. Reliability was evaluated using item-total correlations, Cronbach's α, and intra-class correlation. Validity was evaluated by the content validity index, predictive and discriminative validity. Multiple linear regression was used on the predictors for the severity of uraemic pruritus. RESULTS After optimization for reliability, the scale retained seven items. The Cronbach's α was 0.86, and the results showed that the scale had predictive and discriminative validity. High intact-parathyroid hormone and creatinine clearance rate were important predictors for the severity of uraemic pruritus. The severity of uraemic pruritus was the important predictor for the sleeping disturbance. CONCLUSION The modified uraemic pruritus scale can discriminate between patients with a total pruritus score of ≥11 and those with a score of 0 points. The modified Chinese scale is a useful tool for clinically assessing the various degrees of itching among long-term dialysis patients. Our study validates that it could apply to clinical practice in assessment of uraemic pruritus.
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Affiliation(s)
- Wei-Yun Wang
- Graduate Institute of Medical Sciences, National Defense Medical Centre, Taipei, Taiwan.,Department of Nursing, Tri-Service General Hospital, Taipei, Taiwan
| | - Der-Cherng Tarng
- Division of Nephrology, Department of Medicine, Taipei, Taiwan.,Department and Institute of Physiology, National Yang-Ming University, Taipei, Taiwan
| | - Li-Chi Chiang
- School of Nursing, National Defense Medical Centre, Taipei, Taiwan
| | - Chi-Ming Chu
- School of Public Health, National Defense Medical Centre, Taipei, Taiwan
| | - Kwua-Yun Wang
- Graduate Institute of Medical Sciences, National Defense Medical Centre, Taipei, Taiwan.,Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
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Abstract
Uremic itching is a common problem with multifactorial etiology seen in hemodialysis patients. This study was carried out to determine the factors affecting and incidence of itching in patients undergoing hemodialysis treatment. The descriptive study was carried out in 130 patients who underwent hemodialysis treatment because of end-stage renal disease in Eastern Turkey between October 2014 and December 2014. A questionnaire prepared by the researcher based on the literature and the Visual Analog Scale were used for data collection. The data were collected by the researcher through face-to-face interviews in the hemodialysis unit. The evaluation of data obtained in the research has been performed using SPSS 16.0 software using percentages, chi-square analysis, and t-test. As a result of the study, 85.4% of the patients were found to have itching, the severity of itching was 4.86 ± 3.01 according to Visual Analog Scale, and itching of the patients was found to be affected by serum phosphorus and parathyroid hormone levels. Uremic itching continues to be seen as a problem in hemodialysis patients.
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Affiliation(s)
- Mehtap Kavurmacı
- Department of Internal Medicine Nursing, Faculty of Health Science, Atatürk University, Erzurum, Turkey
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Moon SJ, Kim HJ, Cho SB, Lee SH, Choi HY, Park HC, Ha SK. Epidermal Proteinase-Activated Receptor-2 Expression is Increased in End-Stage Renal Disease Patients with Pruritus: A Pilot Study. Electrolyte Blood Press 2014; 12:74-9. [PMID: 25606046 PMCID: PMC4297706 DOI: 10.5049/ebp.2014.12.2.74] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 12/18/2014] [Indexed: 11/07/2022] Open
Abstract
Uremic pruritus is a common problem in patients with end-stage renal disease (ESRD), but the underlying mechanisms are not yet fully understood. We aimed to investigate the association between severity of uremic pruritus and cutaneous serine protease activity, as well as proteinase-activated receptor-2 (PAR-2) expression. Twelve ESRD patients with pruritus, 4 ESRD patients without pruritus, and 6 healthy controls were enrolled. Skin biopsies were obtained from the abdomen. Protease activity and PAR-2 expression in the epidermis were examined by in situ zymography and confocal laser microscopy, respectively. All ESRD patients presented more pronounced cutaneous protease activity compared with that in healthy controls. The skin samples from the patients with pruritus showed higher protease activity than either nonpruritic ESRD patients or healthy controls. The epidermis in all samples of ESRD patients presented higher immunoreactivity against PAR-2 versus those of healthy controls. In addition, correlation analysis between PAR-2 expression and VAS pruritus scores showed a significant positive correlation. Our data suggests that levels of serine protease and PAR-2 expression could play important roles in the pathogenesis of uremic pruritus.
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Affiliation(s)
- Sung Jin Moon
- Department of Internal Medicine, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Korea
| | - Hyun Jung Kim
- Department of Dermatology/Atopy and Asthma Center & Seoul Medical Research Institute, Seoul Medical Center, Seoul, Korea
| | - Sung Bin Cho
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Hun Lee
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hoon Young Choi
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyeong Cheon Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Kyu Ha
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Hercz D, Jiang SH, Kapoor T, Webster AC. Interventions for itch in people with advanced chronic kidney disease. Hippokratia 2014. [DOI: 10.1002/14651858.cd011393] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Daniel Hercz
- The University of Sydney; Sydney Medical Program; Camperdown NSW Australia 2050
| | - Simon H Jiang
- The Canberra Hospital; Department of Renal Medicine; Yamba Drive Garran ACT Australia 2604
| | - Tanvir Kapoor
- The University of Sydney; Sydney School of Medicine; Sydney NSW Australia
| | - Angela C Webster
- The University of Sydney; Sydney School of Public Health; Edward Ford Building A27 Sydney NSW Australia 2006
- The University of Sydney at Westmead; Centre for Transplant and Renal Research, Westmead Millennium Institute; Westmead NSW Australia 2145
- The Children's Hospital at Westmead; Cochrane Renal Group, Centre for Kidney Research; Westmead NSW Australia 2145
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Receptors, cells and circuits involved in pruritus of systemic disorders. Biochim Biophys Acta Mol Basis Dis 2014; 1842:869-92. [DOI: 10.1016/j.bbadis.2014.02.007] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 02/16/2014] [Accepted: 02/18/2014] [Indexed: 12/12/2022]
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Garibyan L, Chiou AS, Elmariah SB. Advanced aging skin and itch: addressing an unmet need. Dermatol Ther 2013; 26:92-103. [PMID: 23551366 DOI: 10.1111/dth.12029] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Itch is the most common skin disorder in the elderly and frequently diminishes quality of life in this population. The high prevalence of pruritus in elderly patients is attributed in part to the decline in the normal physiology of the advanced aging skin, and reflects poor hydration, impaired skin barrier, and altered neural function, all ultimately contributing to inflammation and pruritus. As the elderly population continues to grow, practitioners need to be aware of how to evaluate and manage pruritus, recognizing the common conditions contributing to itch in elderly patients as well as the challenges of treatment in this group. Ultimately, management of pruritus will require an individually tailored approach that is guided by a patient's general health, severity of symptoms, and the potential adverse effects of itch therapies.
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Affiliation(s)
- Lilit Garibyan
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts 02129, USA
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Wang TJ, Lan LC, Lu CS, Lin KC, Tung HH, Wu SFV, Liang SY. Efficacy of narrowband ultraviolet phototherapy on renal pruritus. J Clin Nurs 2013; 23:1593-602. [DOI: 10.1111/jocn.12252] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Tsae-Jyy Wang
- Department of Nursing; National Taipei University of Nursing and Health Sciences; Taipei Taiwan
| | - Li-Ching Lan
- Department of Nursing; En Chu Kong Hospital; Taipei Taiwan
| | - Chia-Sheng Lu
- Department of Nephorology; En Chu Kong Hospital; Taipei Taiwan
| | - Kuan-Chia Lin
- Department of Health Care Management; National Taipei University of Nursing and Health Sciences; Taipei Taiwan
| | - Heng-Hsing Tung
- Department of Nursing; National Taipei University of Nursing and Health Sciences; Taipei Taiwan
| | - Shu-Fang Vivienne Wu
- Department of Nursing; National Taipei University of Nursing and Health Sciences; Taipei Taiwan
| | - Shu-Yuan Liang
- Department of Nursing; National Taipei University of Nursing and Health Sciences; Taipei Taiwan
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Abstract
A broad range of skin diseases occurs in patients with ESRD: from the benign and asymptomatic to the physically disabling and life-threatening. Many of them negatively impact on quality of life. Their early recognition and treatment are essential in reducing morbidity and mortality. The cutaneous manifestations can be divided into two main categories: nonspecific and specific. The nonspecific manifestations are commonly seen and include skin color changes, xerosis, half-and-half nails, and pruritus. The specific disorders include acquired perforating dermatosis, bullous dermatoses, metastatic calcification, and nephrogenic systemic fibrosis. This review article describes these conditions and considers the underlying pathophysiology, clinical presentations, diagnosis, and treatment options.
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Affiliation(s)
- Timur A Galperin
- Department of Dermatology, St. Louis University, St. Louis, Missouri;, †Medical Research Council Centre for Transplantation and National Institute for Health Research Biomedical Research Centre, King's College, London, United Kingdom, ‡Department of Dermatology, University of California, San Francisco, California
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Uremic pruritus, dialysis adequacy, and metabolic profiles in hemodialysis patients: a prospective 5-year cohort study. PLoS One 2013; 8:e71404. [PMID: 23940749 PMCID: PMC3735516 DOI: 10.1371/journal.pone.0071404] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2012] [Accepted: 07/02/2013] [Indexed: 01/09/2023] Open
Abstract
Background Uremic pruritus is a common and intractable symptom in patients on chronic hemodialysis, but factors associated with the severity of pruritus remain unclear. This study aimed to explore the associations of metabolic factors and dialysis adequacy with the aggravation of pruritus. Methods We conducted a 5-year prospective cohort study on patients with maintenance hemodialysis. A visual analogue scale (VAS) was used to assess the intensity of pruritus. Patient demographic and clinical characteristics, laboratory parameters, dialysis adequacy (assessed by Kt/V), and pruritus intensity were recorded at baseline and follow-up. Change score analysis of the difference score of VAS between baseline and follow-up was performed using multiple linear regression models. The optimal threshold of Kt/V, which is associated with the aggravation of uremic pruritus, was determined by generalized additive models and receiver operating characteristic analysis. Results A total of 111 patients completed the study. Linear regression analysis showed that lower Kt/V and use of low-flux dialyzer were significantly associated with the aggravation of pruritus after adjusting for the baseline pruritus intensity and a variety of confounding factors. The optimal threshold value of Kt/V for pruritus was 1.5 suggested by both generalized additive models and receiver operating characteristic analysis. Conclusions Hemodialysis with the target of Kt/V ≥1.5 and use of high-flux dialyzer may reduce the intensity of pruritus in patients on chronic hemodialysis. Further clinical trials are required to determine the optimal dialysis dose and regimen for uremic pruritus.
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Chan KY, Li CW, Wong H, Yip T, Chan ML, Cheng HW, Sham MK. Use of Sertraline for Antihistamine-Refractory Uremic Pruritus in Renal Palliative Care Patients. J Palliat Med 2013; 16:966-70. [DOI: 10.1089/jpm.2012.0504] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
| | - Cho Wing Li
- Palliative Medical Unit, Grantham Hospital, Hong Kong
| | - Hilda Wong
- Department of Medicine, Queen Mary Hospital, Hong Kong
| | - Terence Yip
- Department of Medicine, Tung Wah Hospital, Hong Kong
| | - Man Lui Chan
- Department of Psychiatry, Kowloon Hospital, Hong Kong
| | - Hon Wai Cheng
- Palliative Medical Unit, Grantham Hospital, Hong Kong
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Welter EDQ, Frainer RH, Maldotti A, Losekann A, Weber MB. Evaluating the association between alterations in mineral metabolism and pruritus in hemodialysis patients. An Bras Dermatol 2012; 86:31-6. [PMID: 21437519 DOI: 10.1590/s0365-05962011000100003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2009] [Accepted: 12/13/2010] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Uremic pruritus is the most frequent symptom in long-term hemodialysis patients. Abnormal laboratory parameters have been found with conflicting data. OBJECTIVE To correlate the prevalence of pruritus with alterations in mineral metabolism in hemodialysis patients. METHODS This was a case-control study. A hundred and five patients on maintenance hemodialysis were evaluated: a group of patients with pruritus and a control group. They answered a research protocol questionnaire; laboratory data were collected from medical records and the patients with pruritus filled out a visual analogue scale (VAS) to measure pruritus level. RESULTS The mean age was 51.9 years; 59% of the patients were men and 43% of the patients had pruritus. Xeroderma occurred in 45% of the patients. High levels of calcium were demonstrated in 55% of the patients and 47% had pruritus. 60% of the patients had high phosphorus levels and 43% had pruritus. The Ca/P ratio was normal for all the patients. Parathyroid hormone was high in 95% of the patients, all of them referring pruritus. CONCLUSION There was a statistically significant association between the group of patients with pruritus and xeroderma. Serum calcium and phosphorus levels, Ca/P ratio, PTHi and size of the dialyzer did not show a statistically significant association with pruritus. Therefore, we found an important relationship between xeroderma and pruritus, with no relation with the assessed laboratory parameters.
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Aucella F, Vigilante M, Gesuete A. Review: the effect of polymethylmethacrylate dialysis membranes on uraemic pruritus. NDT Plus 2010; 3:i8-i11. [PMID: 27045813 PMCID: PMC4813819 DOI: 10.1093/ndtplus/sfq031] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Filippo Aucella
- Department of Nephrology and Dialysis , Scientific Institut 'Casa Sollievo della Sofferenza' Hospital , San Giovanni Rotondo , Italy
| | | | - Antonio Gesuete
- Department of Nephrology and Dialysis , Scientific Institut 'Casa Sollievo della Sofferenza' Hospital , San Giovanni Rotondo , Italy
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Abstract
Chronic pruritus, one of the main symptoms in dermatologic diseases, is often intractable and has a high impact on a patient´s quality of life. In addition to dermatologic disorders, chronic pruritus is associated with systemic and neurologic, as well as psychologic, diseases. Aging skin is considered to be more susceptible to pruritic disorders. Thus, owing to demographic changes, pruritus is becoming more prevalent. The elderly are often afflicted with comorbidities and polypharmacy, which can complicate diagnosis and therapy. In this review we present a rational work-up adapted to the special premises and needs of geriatric patients. This may facilitate the choice of suitable therapeutic regimens.
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Affiliation(s)
- Sonja A Grundmann
- Neurodermatology & Competence Center Pruritus, Department of Dermatology, University of Münster, Germany
| | - Sonja Ständer
- Neurodermatology & Competence Center Pruritus, Department of Dermatology, University of Münster, Germany
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47
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[Pruritus and dryness of the skin in chronic kidney insufficiency and dialysis patients - a review]. Wien Med Wochenschr 2009; 159:317-26. [PMID: 19652938 DOI: 10.1007/s10354-009-0643-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2008] [Accepted: 10/08/2008] [Indexed: 10/20/2022]
Abstract
The uremic pruritus is a very painful symptom suffered by chronic haemodialysis patients and is observed in 22 to 74% of the subjects. The causes of uremic pruritus have not yet been clarified. During the last 20 to 30 years it has been focused on altogether 5 different pathophysiological hypotheses: stimulating influences (e.g. calcium phosphate deposits in the epidermis), stimuli (e.g. secondary hyperparathyroidism), neuropathic injuries (e.g. disturbance of the cutaneous innervation in patients with uremic peripheral neuropathy), and central nervous changes (e.g. accumulation of endorphins in uremic patients which is associated with increasing pruritus), and immunologic conditions. The last mentioned immunological hypothesis has increasing importance, not at least based on the fact that the application of a topical calcineurin inhibitor (tacrolimus) improves the uremic pruritus. However, this fact could not be confirmed in a recent prospective placebo-controlled study from the USA. Only after kidney transplantation with a functioning transplant the uremic pruritus is stopped. That is why no causal therapy exists so far. Actually, the uremic pruritus has to be treated by topical and systemic means in a symptomatic and polypragmatic way only. Urea represents one of the most important "natural moisturizing factors" which are responsible for the hydration of the skin. It has been demonstrated that older patients have decreased urea levels within the stratum corneum of the epidermis, whereas in patients with terminal kidney insufficiency - despite dryness of the skin - as a paradox finding elevated levels of urea have been assessed in the stratum corneum. Because of this reason, the meaning of urea as part of the "natural moisturizing factors" system is not understood, until now. However, there are very promising results of clinical phase II studies showing a significant effect of topical application of 2.5% L-arginine hydrochlorid ointment - a semi-essential amino acid - on improvement of dryness and, in particular, on improvement of pruritus in haemodialysis patients.
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48
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Young TA, Patel TS, Camacho F, Clark A, Freedman BI, Kaur M, Fountain J, Williams LL, Yosipovitch G, Fleischer AB. A pramoxine-based anti-itch lotion is more effective than a control lotion for the treatment of uremic pruritus in adult hemodialysis patients. J DERMATOL TREAT 2009; 20:76-81. [DOI: 10.1080/09546630802441218] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Manenti L, Tansinda P, Vaglio A. Uraemic pruritus: clinical characteristics, pathophysiology and treatment. Drugs 2009; 69:251-63. [PMID: 19275270 DOI: 10.2165/00003495-200969030-00002] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Pruritus is a common complication of end-stage renal disease (ESRD), affecting about one-third of dialysis patients. It is a chronic, unpleasant symptom with a strong negative impact on patients' quality of life, often inducing sleeplessness and mood disorders. Recent data show that it is also associated with increased mortality. The pathogenesis of uraemic pruritus (UP) is multifactorial. Triggering factors may include uraemia-related abnormalities (particularly involving calcium, phosphorus and parathyroid hormone metabolism), accumulation of uraemic toxins, systemic inflammation, cutaneous xerosis, and common co-morbidities such as diabetes mellitus and viral hepatitis. Recent findings suggest that the neurophysiology of itch is similar to that of pain; this has led to the hypothesis that the two phenomena also closely interact in ESRD patients, who often also experience uraemic neuropathy. The management of UP needs to address several different issues, such as optimization of dialysis efficacy and skin hydration, and correction of calcium-phosphorus metabolism abnormalities. A wide range of antipruritic drugs have been suggested for the treatment of UP, although most of them have only been tested in small, uncontrolled trials, which have yielded conflicting results. Antihistamines are now known to have little or no efficacy, although they are still often prescribed. Novel neurotropic drugs such as gabapentin, along with opioid receptor modulators such as nalfurafine, appear to be effective and well tolerated, but their efficacy has not yet been directly compared. Finally, physical therapies, including UV radiation, may also have a role in patients with refractory symptoms.
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Affiliation(s)
- Lucio Manenti
- Division of Nephrology, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy.
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50
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Melo NCV, Elias RM, Castro MCM, Romao JE, Abensur H. Pruritus in hemodialysis patients: the problem remains. Hemodial Int 2009; 13:38-42. [PMID: 19210276 DOI: 10.1111/j.1542-4758.2009.00346.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Pruritus is still one of the most common and disturbing symptoms of end-stage renal disease. The objective of this study is to analyze the prevalence of pruritus in hemodialysis patients and the possible factors implicated in its genesis. In a cross-sectional study, 101 patients on hemodialysis at our center were screened for pruritus. The relationship of various factors with pruritus was evaluated. Of the 101 patients included, 31(30.7%) had pruritus at the time of examination. Patients with pruritus were significantly older than those without pruritus (P=0.0027). Pruritus tended to be more prevalent in patients undergoing dialysis 3 times a week than in those undergoing daily dialysis, but the difference did not reach statistical significance (P=0.0854). Lower transferrin saturation levels were found in patients with pruritus than in those without pruritus (P=0.0144). C-reactive protein levels were significantly higher in patients with pruritus than in those without pruritus (P=0.0013). There was no significant difference between the groups in the levels of the other inflammatory biomarkers measured. However, there was a tendency toward a correlation between the levels of alpha-1-glycoprotein and the intensity of pruritus (P=0.0834). Our results suggest a possible relationship of the inflammatory response upregulation to pruritus. Additionally, there was a positive relationship between pruritus and iron deficiency, possibly associated with inflammatory elevation of hepcidin. A better understanding of the factors implicated in the genesis of pruritus related to end-stage renal disease is crucial in the development of more effective treatments for this symptom.
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