Uremic pruritus: a review

Effect of Dill (Anethum graveolens) Oil on Pruritus and Quality of Life of Hemodialysis Patients: A Randomized Double-Blind Three-Arm Controlled Trial

Introduction

Anethum graveolens (AG), commonly known as dill, is a plant from the Apiaceae family that has been traditionally used as a skin softener and purifying agent in Persian medicine. In a previous study conducted on male rats, dill was found to have anti-inflammatory effects. The current study aimed to examine the efficacy of topical application of Anethum graveolens oil on pruritus severity, skin dryness, sleep quality, and quality of life in patients undergoing hemodialysis.

Methods

In the current clinical trial, the participants were randomly assigned to one of these groups: topical AG preparation, sesame oil, or a control group receiving no treatment. The study was double-blind and placebo-controlled. The topical treatment was applied twice a day for one month to areas of the skin affected by pruritus. The outcome measures included the severity of skin dryness, the Pittsburgh Sleep Quality Index, Duo's Uremic Pruritus Severity Scale, and the Itchy QoL questionnaire.

Results

This study involved 106 hemodialysis patients, and after intervention for one month, the medication group had a significantly lower mean score of sleep quality (3.24 ± 2.41) than the placebo (4.54 ± 3.11) and control (5.05 ± 3.21) groups (P=0.032). The mean change in pruritus severity was significantly greater in the medication group (-17.28 ± 8.938) than the placebo (-5.91 ± 5.398) and control (-3.43 ± 3.228) groups (P < 0.001). Moreover, a significant difference was observed in the mean changes in quality of life between the medication, placebo, and control groups, with values of -14.88 ± 7.89, -5.34 ± 4.50, and -1.92 ± 2.86, respectively (P < 0.001). Furthermore, both the medication and placebo groups showed improvement in skin dryness compared to the control group having the values of -1.65 ± 0.91, -1.11 ± 0.79, and -0.38 ± 0.54, respectively (P < 0.001).

Conclusion

Topical Anethum graveolens preparation significantly improved the sleep quality and quality of life and reduced skin pruritus and dryness in hemodialysis patients. It could be considered as a simple therapeutic modality to control pruritus in hemodialysis patients. This trial is registered with IRCT2017022032671N1.

Chronic Kidney Disease-Associated Pruritus and Quality of Life: Learning from Our Patients

Chronic kidney disease-associated pruritus is itching directly related to kidney disease that cannot be explained by any other condition. Despite technological advances in the different aspects of dialysis sessions and the best treatment for chronic kidney disease patients, it is still a common problem in our patients. The many complex physiological mechanisms involved, the different hypotheses made over the years on the aetiology of the condition, and the great clinical variability may partially explain the limited knowledge about this problem and the difficulties in treating it. The presence of all these factors leads to the persistence of unpleasant symptoms, which must affect the disease burden and quality of life of kidney patients. Through the presentation of an illustrative clinical case, the aim of this review article is to highlight the need for adequate diagnosis and an improved approach to all aspects of chronic kidney disease-associated pruritus, in view of the heavy burden of the disease and the huge impact on the patient's quality of life.

Incidence and Risk Factors for Pruritus in Patients with Nondialysis CKD

BACKGROUND

Pruritus is a common symptom experienced by patients with nondialysis CKD, but risk factors for incident pruritus in this patient population have not been evaluated.

METHODS

We identified 1951 participants with CKD in the Chronic Renal Insufficiency Cohort Study without pruritus at the baseline assessment. Pruritus was assessed by the Kidney Disease Quality of Life-36 (KDQOL-36) instrument, and moderate-to-severe pruritus was defined as a response of 3 or higher on a Likert scale of 1-5. We used time-updated multivariable joint models to evaluate the association of patient clinical characteristics, eGFR, and laboratory parameters with incident pruritus.

RESULTS

Over a median follow-up of 6 years, 660 (34%) participants developed incident moderate-to-severe pruritus, with a higher incidence rate observed among participants with more advanced CKD. In multivariable models, the hazard ratio (95% confidence interval [CI]) for pruritus associated with a 10 ml/min per 1.73 m 2 lower eGFR was 1.16 (95% CI, 1.10 to 1.23). Older age (≥65 years), higher body mass index, diabetes, current smoking, opioid use, depressive symptoms, and serum parathyroid hormone were also associated with a higher risk of incident pruritus, whereas low serum calcium (<9 mg/dl) was associated with a lower risk (all P <0.05). Serum phosphate was not associated with incident pruritus in the primary analysis.

CONCLUSIONS

A substantial proportion of patients with nondialysis CKD develop moderate-to-severe pruritus. Although lower eGFR is associated with the risk of pruritus, other comorbidities, particularly depressive symptoms, were potential risk factors.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2023_02_08_CJN09480822.mp3.

Obstacles to Early Diagnosis and Treatment of Pruritus in Patients with Chronic Kidney Disease: Current Perspectives

Chronic kidney disease-associated pruritus (CKD-aP) is a common condition amongst patients with advanced chronic kidney disease (CKD). Several studies have confirmed that more than four out of ten early-stage CKD patients suffer from this condition, while its prevalence among CKD patients on dialysis reaches up to seven out of ten. It is noted to be associated with other disabling symptoms and serious outcomes. It has significant impact on sleep, mood, daily activities, and quality of life of CKD patients, and increased mortality risk of patients on hemodialysis. The Dialysis Outcomes and Practice Patterns Study found 17% higher mortality among patients with moderate to extreme pruritus compared with patients with no or mild pruritus. Despite its high prevalence, ill-effect, and suffering associated with it, CKD-aP remains surprisingly under-reported on the patient's part and under-recognized by the healthcare team. Even upon being noticed, it remains unattended and poorly treated. Its etiopathogenesis is complex and not fully understood. Many treatment options are available but good quality evidence about most of those is absent, and to date, only two medications are approved for use in this condition. While a validated guideline is very much required for the benefit of the patients and caretakers, further research on several aspects of this issue is required.

Complementary and integrative remedies in the treatment of chronic pruritus: A review of clinical trials

BACKGROUND

Chronic pruritus is one of the most common conditions in dermatology and a common manifestation in many systemic diseases. Since the etiology of chronic pruritus remains somewhat unknown, hence, conventional medications may not always show a good therapeutic response. This finding has led both investigators and patients to use herbal and complementary remedies for its treatment. The aim of this study was to review clinical trials in which herbal and complementary medicine was used in the control and treatment of chronic pruritus.

MATERIALS AND METHODS

In this study, we reviewed related articles in this domain, from 2000 to 2020. The search involved electronic databases including PubMed, Scopus, Web of Science, Cochrane, Google Scholar, and SID databases using the keywords "pruritus," "itch," "herb," "complementary medicine," "traditional medicine," "integrative medicine," and their related MeSH terms. Finally, we extracted the pertinent information from these articles and summarized the results.

RESULTS

The findings of this study showed that 17 clinical trials have been conducted till date in order to evaluate the efficacy of herbal remedies and complementary medicines in the treatment of chronic pruritus. Herbal remedies including turmeric, Fumaria parviflora, Avena sativa, capsaicin, sweet almond oil, peppermint oil, violet oil, vinegar, as well as manual therapies including aromatherapy, auricular acupressure, and acupuncture, were significantly effective in the treatment of chronic pruritus.

CONCLUSION

There are only a few studies published on the therapeutic efficacy of herbal remedies and complementary medicine in the treatment of chronic pruritus. Some have shown promising results. Therefore, more evidence-based studies are needed in order to determine if herbal remedies and complementary medicine could be an effective alternative or adjuvant treatment modality in chronic pruritus.

Lettuce as an Effective Remedy in Uremic Pruritus: Review of the Literature Supplemented by an In Silico Study

Uremic pruritus is a frequent and prominent symptom in patients with advanced or end-stage renal disease. Lack of an effective treatment for kidney disease-associated pruritus often leads to many problems for these patients and makes it difficult to choose an appropriate treatment. The purpose of this evidence-based hypothesis is to share the scientific reasons and related mechanisms in order to claim that lettuce could be useful in the treatment of uremic pruritus. This hypothesis is based on studies related to lettuce and its anti-inflammatory, antioxidant, antidiabetic, sedative, hypnotic, nephroprotective, potassium balancing, and blood purification properties. As a result, we suggest that lettuce could be a good choice for improving and reducing uremic pruritus due to its certain characteristics. Although proof of this hypothesis requires further clinical trial studies, this hypothesis can nevertheless lead to formulating an appropriate therapy for uremic-induced pruritus. By conducting a molecular docking study, we investigated the interactions between nineteen natural bioactive components of lettuce (Lactuca sativa L.) and human kappa opioid receptors. The in silico docking studies revealed that most of the ligands showed better antipruritic efficacy than gabapentin. Gamma-tocopherol, delta-tocopherol, and campesterol demonstrated the highest binding affinities toward the target protein.

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

Chronic kidney disease (CKD) is recognized as a leading public health problem and causes numerous health complications. One of the most common and burdensome dermatological symptoms affecting patients undergoing dialysis is CKD-associated pruritus (CKD-aP). This condition not only has a negative impact on sleep, mood, daily activities, and quality of life but also increases the mortality risk of hemodialyzed patients. Despite that, this condition is greatly underestimated in clinical practice. Due to the complex and still not fully understood etiopathogenesis of CKD-aP, the choice of an effective therapy remains a challenge for clinicians. Most common therapeutic algorithms use topical treatment, phototherapy, and various systemic approaches. This review aimed to summarize most recent theories about the pathogenesis, clinical features, and treatment of CKD-aP.

Systemic causes of non-dermatologic chronic pruritus in the pediatric population and their management: An unexplored area

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.

The correlation between uremic pruritus and blood lead levels in prevalent hemodialysis patients and its relation to the severity of pruritus using visual analog score

Background

Pruritus is a common and often distressing symptom in patients with chronic kidney disease. Though the pathogenesis of uremic pruritus remains poorly understood, systemic inflammation has presented itself as one of the possible explanations. High blood lead levels (BLLs) have been noted to be associated with inflammation and poor nutritional status in hemodialysis patients. Our aim is to study the relation between blood lead levels and uremic pruritus. This is a cross-sectional study that enrolled 50 patients; all were on regular hemodialysis 3 times per week for at least 6 months. Patients were divided into 2 groups, group 1 (n =10) with no pruritus and group 2 (n=40) with varying degrees of pruritus. Group 2 was further divided according to intensity of pruritus by visual analog score (VAS) into mild (n=10), moderate (n=20), and severe pruritus (n=10).

Results

There was a significant difference in serum lead levels and ferritin levels between groups 1 and 2 (p value < 0.01 and < 0.05, respectively). There was a statistically significant difference in serum lead levels in the groups with varying intensity of pruritus, having higher serum lead levels in patients who exhibited severe pruritus (p value < 0.005) Moreover, a statistically significant relation between elevated blood lead levels and the duration of dialysis was observed in this study.

Conclusion

Uremic pruritus is a multi-factorial phenomenon, and our study showed that blood lead levels in hemodialysis patients might be associated with increased intensity of pruritus.

Effectiveness and safety of different medicines for Uremia pruritus: A protocol for systematic review and network meta analysis

INTRODUCTION

A large number of patients will experience pruritus after uremia. Medicine is the preferred treatment for many doctors, but the effectiveness and safety of different medicines for uremia pruritus has not yet been comprehensively compared, based on network meta-analysis.

METHODS AND ANALYSIS

According to the retrieval strategy, two team members independently searched the literature in 7 databases, and imported the retrieval results into the EndNote Software AQ8 (V.X9). After deleting repeated articles, they read the abstract and the full text, selected the articles that met the inclusion criteria and extracted valid information. The main results were visual analogue scale (VAS) and the secondary results were verbal rating scale (VRS), Dirk R Kuypers score, and adverse event incidence. The methodological quality evaluation was conducted from 7 aspects, according to The Cochrane Collaborative Tool, Stata Statistical Software (Version 14.0, Stata Corporation, College Station, TX) was used for data analysis. The level of evidence will be assessed by the Grading of Recommendations, Development and Evaluation (GRADE) instrument).

RESULTS

The results will rank the efficacy of drugs used to treat uremic pruritus and assess their safety.

CONCLUSION

This study is the first to compare the efficacy and safety of medicines for uremic pruritus based on network analysis and will provide evidence and ideas for the treatment of uremic pruritus.

INPLASY REGISTRATION NUMBER

No. INPLASY202090103.

Evaluation of Efficacy of Mirtazapine on Pruritus and Serum Histamine and Serotonin Levels in Patients Undergoing Hemodialysis: A Before-After Pilot Clinical Trial

Background

Although chronic kidney disease-associated pruritus (CKD-aP) remains a frequent and frustrating symptom in patients with advanced kidney diseases, its optimal treatments are not well defined. Based on its mechanism of action, as a histamine-1 (H1), 5-(hydroxytryptamine) HT2, and 5HT3-receptor blocker, mirtazapine may be effective in the treatment of CKD-aP. Hence, this study aimed to investigate the efficacy of mirtazapine for the treatment of pruritus in patients undergoing hemodialysis (HD).

Methods

A before-after clinical trial was conducted from September 2018 until March 2019, on 30 HD-patients that had been referred to the HD ward of a tertiary hospital, in Hamadan, Iran. After the 2-week washout period, mirtazapine was administered with a dosage of 15 mg/day for an additional 2 weeks. At baseline and at each dialysis session, the effects of the mirtazapine on the pruritus severity based on the visual analogue scale (VAS) and degree of sleep interference resulting from the pruritus were asked and recorded. Additionally, at the baseline and the end of 2 weeks of treatment, the serum histamine and serotonin levels, as the main chemical pruritogens evoking pruritus symptoms, were also determined.

Results

Twenty-seven patients completed the entire course of the study. Based on the general linear model analysis, a progressive decline in the mean VAS score was observed over time during the study. The mean VAS score decreased from 8.48 ± 1.01 at baseline to 1.04 ±0.79 at the end of treatment (P-value<0.001). Similarly, the mean sleep interference scores were also significantly improved throughout treatment (decreased from 8.07±1.43 to 2.81± 0.74; P-value<0.001). Further, at the end of the treatment, a noticeable decrement in the serum histamine level was also seen (P-value = 0.006). The drug was acceptably well-tolerated and a majority of the patients were satisfied with this treatment.

Conclusion

This pilot study suggests that mirtazapine may be an effective treatment option for the management of CKD-aP. However, further studies would be needed to confirm these results.

Effect of mirtazapine on pruritus in patients on hemodialysis: a cross-over pilot study

BACKGROUND

Uremic pruritus (UP) is a highly prevalent and disturbing problem in patients with advanced chronic kidney disease (CKD); however, treatment of UP is largely unsatisfactory. The present study was designed to investigate the effectiveness of mirtazapine, an atypical antidepressant agent with potent antagonistic activity against serotonin (5HT2, 5HT3) and histamine (H1) receptors, in the treatment of pruritus in hemodialysis (HD) patients.

METHODS

An 8-week long, prospective, open-label, and cross-over randomized clinical trial study was conducted on 77 HD patients with chronic pruritus. After a 2-week washout period, eligible patients were randomly assigned either to the mirtazapine (15 mg per day) or gabapentin (100 per day) for 2 weeks. Following 2 weeks washout period, subjects crossed over to the other treatment arm for 2 more weeks. The severity of pruritus was measured seven times during each treatment period using the visual analogue scale (VAS). Furthermore, at the end of the study, patients also were blindly asked which treatment (first or last in the sequential course of the study) they preferred.

RESULTS

Sixty-one patients completed two treatment periods of the study. Although, compared to baseline, both gabapentin and mirtazapine treatment resulting in significant improvement in VAS scores, decreasing in pruritus severity was significantly greater in the mirtazapine treatment period compared with the gabapentin treatment period (P < 0.001). Furthermore, although side effects such as drowsiness and dry mouth more reported in the mirtazapine treatment period, overall higher percentage of the study patients preferred mirtazapine over gabapentin for the treatment of their pruritus symptoms.

CONCLUSIONS

Although preliminary, our study provides evidence that mirtazapine can be an effective therapy for UP in patients who are on maintenance HD. However, further studies would be necessary to confirm effectiveness as well as the safety of mirtazapine in the long-term management of chronic pruritus.

CKD-Associated Pruritus: New Insights Into Diagnosis, Pathogenesis, and Management

Chronic kidney disease–associated pruritus (CKD-aP) is a common, troubling and in some cases debilitating problem for patients with CKD and end-stage renal disease. Despite a prevalence rate of approximately 20% in CKD and 40% in end-stage renal disease, and a clear association with poorer psychosocial and medical outcomes, this condition is often underreported by patients and overlooked by health care providers. This is likely due, in part, to uncertainty regarding its pathogenesis and treatment. Most commonly, CKD-aP is attributed to toxin build-up, peripheral neuropathy, immune system dysregulation, or opioid dysregulation. Prior treatment studies of CKD-aP have targeted these potential etiologies but have been limited by noncontrolled design, small sample size, and non-uniform definitions of CKD-aP. Recently, several large, randomized controlled trials targeting opioid dysregulation have yielded promising results. These trials have spurred new hope for understanding and treating this condition.

The effect of massage and topical violet oil on the severity of pruritus and dry skin in hemodialysis patients: A randomized controlled trial

BACKGROUND

Pruritus is one of the common problems in hemodialysis patients that involves more than 45% of Iranian patients. Its exact pathogenesis is unclear. Meanwhile, violet is an old plant with anti-scratching effects, which is extensively used to treat diseases in the Persian medicine. This study aimed to evaluate the effect of massaging the body with and without violet oil in the treatment of uremic pruritus.

METHODS

In this study 57 hemodialysis patients who had uremic pruritus were categorized randomly into two groups. The treatment involved massage with and without topical 5 ml violet oil for 7 min during six sessions (two weeks) on the healthy hand which did not have fistula pruritus score questionnaire were completed before and after the intervention.

RESULTS

There was no difference between the two groups before the intervention; however, after the intervention, a significant difference was observed within each group and between the groups in terms of skin dryness score, severity, location, and frequency of pruritus, which were recovered significantly in both groups.

CONCLUSION

The results of this study indicated that massage with violet oil is more effective than massage alone and is recommended as a complementary treatment for patients with uremic pruritis.

Pruritus Associated With Chronic Kidney Disease: A Comprehensive Literature Review

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.

Chronic Renal Failure as a Possible Risk Factor for Allergic Reaction in Therapeutic Plasma Exchange Using Fresh Frozen Plasma

The incidence of allergic reactions in patients with chronic renal failure during plasma exchange using fresh frozen plasma is not well known. We retrospectively reviewed 62 patients who underwent plasma exchange between January 2013 and May 2018. The most common indication for plasma exchange was desensitization/preconditioning for kidney transplant (61.3%, 38/62). The incidence of allergic reactions was significantly higher in patients with chronic renal failure than patients without (57.1% vs. 25.0%, P = 0.029). Also, the incidence of allergic reactions tended to be higher in peritoneal dialysis patients (75%, 3/4) than in hemodialysis (58.8%, 10/17) and preemptive kidney transplant (58%, 11/19). These results suggested the relationship of chronic renal failure and the incidence of allergic reactions in patients undergoing therapeutic plasma exchange using fresh frozen plasma.

Effects of Hemodialysis on the Symptom Burden of Terminally Ill and Nonterminally Ill End-Stage Renal Disease Patients

BACKGROUND

No study has compared the effects of hemodialysis on the symptom burden of terminally ill and nonterminally ill end-stage renal disease (ESRD) patients.

OBJECTIVES

This study aimed to examine the effects of hemodialysis on the symptom burden of ESRD patients and compare the terminally ill and nonterminally ill groups.

DESIGN

This was a quantitative survey; for patients on hemodialysis, the survey was conducted at the beginning and end of the weekly cycle of hemodialysis sessions.

SETTING/SUBJECTS

A total of 211 ESRD patients were recruited in Taiwan, 47 of which were terminally ill (38 on hemodialysis) and 164 nonterminally ill (110 on hemodialysis).

MEASUREMENTS

Symptom burden was assessed using the Taiwanese version of the MD Anderson Symptom Inventory for kidney disease.

RESULTS

Being terminally ill predicted higher symptom severity (B = 0.604, p = 0.017), whereas hemodialysis predicted lower symptom severity (B = -0.614, p = 0.014) in ESRD patients. Nonterminally ill patients who were married or on hemodialysis experienced lower symptom severity (B = -0.604, p = 0.013 and B = -0.665, p = 0.017, respectively). Among terminally ill patients, neither hemodialysis nor other background characteristics predicted symptom severity. When hemodialysis was initiated, no change in symptom severity was observed in terminally ill and nonterminally ill patients.

CONCLUSIONS

The effects of hemodialysis on symptom burden were different between ESRD patients with different disease states. Hemodialysis predicted lower symptom severity only in nonterminally ill ESRD patients. Apart from dialysis, care providers should revisit the palliative approach for treating terminally ill ESRD patients to improve their quality of life.

Dermatologic manifestations in end stage renal disease

Skin manifestations are commonly seen in end stage renal disease (ESRD). Skin involvement in this population can be extensive and dramatically worsen quality of life. Close observation of the skin and nails of ESRD patients by clinicians allows for timely diagnosis and treatment, which ultimately improves quality of life and reduces mortality. In this article we focus on the cutaneous changes most commonly seen in ESRD patients. PubMed/Medline database search was done for published literature on skin manifestations in ESRD patients. All the available literature was reviewed and relevant articles were used to discuss about clinical features, pathogenesis, histology and treatment of each skin disorder in ESRD patients. Most commonly encountered skin manifestations in patients with ESRD are pruritus, xerosis, pigmentation changes, nail changes, perforating disorders, calcifying disorders, bullous dermatoses and nephrogenic systemic fibrosis. Skin manifestations in ESRD can be difficult to treat and multiple comorbidities in this patient population can exacerbate these disorders. Many of the treatment options are experimental with evidence largely derived from the case reports and small clinical trials. More large-scale trials are needed to firmly establish evidence based treatment guidelines. Prompt evaluation and management of these disorders improve morbidity and quality of life in ESRD patients.

Association Between Serum Aluminum Level and Uremic Pruritus in Hemodialysis Patients

Uremic pruritus (UP) is a common symptom in patients undergoing hemodialysis (HD). The pathogenesis of UP is complex. Aluminum (Al) is a common metal and is toxic to patients undergoing HD. Al is also a known human allergen which can induce immune reactions. However, the correlation between Al and UP remains unclear in dialysis patients. A total of 866 patients on maintenance HD were enrolled for analysis. The HD patients with higher serum Al levels had higher a prevalence of UP than those with lower serum Al levels. After adjusting for confounding variables, the serum Al level was significantly associated with UP. Overall, each 10-fold increase in serum Al level was associated with a 5.64-fold increase in the risk of developing UP in these subjects. The results of this cross-sectional study suggest that serum Al level may be associated with the development of UP in patients on maintenance HD.

Prevalence of chronic kidney disease-associated pruritus among adult dialysis patients: A meta-analysis of cross-sectional studies

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.

Exploring sleep disorders in patients with chronic kidney disease

Kidney disorders have been associated with a variety of sleep-related disorders. Therefore, researchers are placing greater emphasis on finding the role of chronic kidney disease (CKD) in the development of obstructive sleep apnea and restless legs syndrome. Unfortunately, the presence of other sleep-related disorders with CKDs and non-CKDs has not been investigated with the same clinical rigor. Recent studies have revealed that myriad of sleep disorders are associated with CKDs. Furthermore, there are a few non-CKD-related disorders that are associated with sleep disorders. In this narrative review, we provide a balanced view of the spectrum of sleep disorders (as identified in International Classification of Sleep disorders-3) related to different types of renal disorders prominently including but not exclusively limited to CKD.

Uremic Pruritus

Renal itch is a localized or generalized itch, affecting patients with chronic renal failure, where there is no primary skin disease and no systemic or psychological dysfunction that might cause pruritus. Uremic pruritus (UP) is an unpleasant sensation, rarely appearing in earlier stages of chronic kidney disease. Renal transplantation is the definite solution for that problem. The prevalence of UP has been reduced during the last years, possibly, due to a more efficient dialysis, with more biocompatible filters.

During the last decades a big number of substances were considered to be etiologic factors of UP, and an even bigger number of therapeutic substances appeared with promising potentials and conflicting results in the course of their use. The main reason for this disorientation is the lack of sound evidence on the pathogenetic mechanisms that may potentiate UP.

‘Inflammatory’ and ‘opioid’ hypothesis are the best studied and the reduction of UP is a fact. Nevertheless the mechanisms of the pathogenesis of UP are still under investigation and a long way has to be done in order to achieve more definite results.

Omega-3 Supplementation Improves Pruritus in Continuous Ambulatory Peritoneal Dialysis Patients: A Crossover Randomized Pilot Clinical Trial

Objective:

Pruritus is a prevalent skin condition in end-stage renal disease patients. Omega-3 fatty acids have been shown to reduce pruritus in hemodialysis patients. Our objective was to assess the effect of 3 g/day omega-3 supplementation on pruritus among continuous ambulatory peritoneal dialysis (CAPD) patients.

Methods:

In this two-period, two-sequence crossover randomized clinical trial, 40 eligible subjects (CAPD patients who complained of pruritus for more than 8 weeks) were randomized to 3 g of omega-3 (n = 20) or identical placebo capsules (n = 20) for 4 weeks. After a wash-out period of 6 weeks, patients were crossed over to the alternate treatment option. Pruritus intensity was assessed using the visual analog scale (VAS) at baseline, 2-and 4-weeks post-intervention in each study period. Both patients and investigators were blinded to the study protocol.

Findings:

No significant carry-over effect was detected. The mean pruritus score (VAS) in the omega-3 group compared with placebo group after the first (−3.02 vs. −0.48, P < 0.001) and second (−4.09 vs. −0.43, P < 0.001) intervention periods showed higher significant decrease.

Conclusion:

In summary, omega-3 supplementation is an effective treatment for pruritus alleviation in CAPD patients. Further studies are needed to determine the mechanisms underlying antipruritic effects of omega-3.

Treatment of Uremic Pruritus: A Systematic Review

BACKGROUND

Uremic pruritus is a common and burdensome symptom afflicting patients with advanced chronic kidney disease (CKD) and has been declared a priority for CKD research by patients. The optimal treatments for uremic pruritus are not well defined.

STUDY DESIGN

Systematic review.

SETTING & POPULATION

Adult patients with advanced CKD (stage ≥ 3) or receiving any form of dialysis.

SELECTION CRITERIA FOR STUDIES

PubMed, CINAHL, Embase, International Pharmaceutical Abstracts, Scopus, Cochrane Library, and ClinicalTrials.gov from their inception to March 6, 2017, were systematically searched for randomized controlled trials (RCTs) of uremic pruritus treatments in patients with advanced CKD (stage ≥ 3) or receiving any form of dialysis. 2 reviewers extracted data independently. Risk of bias was assessed using the Cochrane Collaboration risk-of-bias tool.

INTERVENTION

Any intervention for the treatment of uremic pruritus was included.

OUTCOMES

A quantitative change in pruritus intensity on a visual analogue, verbal rating, or numerical rating scale.

RESULTS

44 RCTs examining 39 different treatments were included in the review. These treatments included gabapentin, pregabalin, mast cell stabilizers, phototherapy, hemodialysis modifications, and multiple other systemic and topical treatments. The largest body of evidence was found for the effectiveness of gabapentin. Due to the limited number of trials for the other treatments included, we are unable to comment on their efficacy. Risk of bias in most studies was high.

LIMITATIONS

Heterogeneity in design, treatments, and outcome measures rendered comparisons difficult and precluded meta-analysis.

CONCLUSIONS

Despite the acknowledged importance of uremic pruritus to patients, with the exception of gabapentin, the current evidence for treatments is weak. Large, simple, rigorous, multiarm RCTs of promising therapies are urgently needed.

Association of uremic pruritus in hemodialysis patients with the number of days of high mean 24-hour particulate matter with a diameter of <2.5 μm

Uremic pruritus (UP) is a common and incapacitating symptom in patients undergoing hemodialysis (HD). The pathogenesis of UP is multifactorial and complex. Particulate matter (PM), a major air pollutant, is a mixture of particles with various chemical compositions. PM is associated with several allergic diseases, including dermatitis. To assess the role of PM (PM with a diameter of <10 μm [PM10] and PM with a diameter of <2.5 μm [PM2.5]) and other clinical variables in UP in patients on HD, we recruited 866 patients on maintenance HD (MHD). We analyzed the number of days of mean 24-hour PM10 ≥125 μg/m3/12 months (NDPM10) or the number of days of mean 24-hour PM2.5 ≥35 μg/m3/12 months (NDPM2.5) exceeding the standard level in the past 12 months respectively to determine the association with UP. In a multivariate logistic regression, HD duration, serum ferritin levels, low-density lipoprotein (LDL) levels, and NDPM2.5 ≥116 days/12 months were positively associated with UP. This cross-sectional study showed that the number of days on which the environmental PM2.5 exceeds the standard level might be associated with UP in patients on MHD.

Chronic kidney disease-associated pruritus: impact on quality of life and current management challenges

Chronic kidney disease-associated pruritus (CKD-aP) is a distressing, often overlooked condition in patients with CKD and end-stage renal disease. It affects ~40% of patients with end-stage renal disease and has been associated with poor quality of life, poor sleep, depression, and mortality. Prevalence estimates vary based on the instruments used to diagnose CKD-aP, and standardized diagnostic instruments are sorely needed. Treatment studies have often yielded conflicting results. This is likely related to studies that are limited by small sample size, flawed designs, and nonstandardized diagnostic instruments. Several large well-designed treatment trials have recently been completed and may soon influence CKD-aP management.

Targeting the Opioid Pathway for Uremic Pruritus: A Systematic Review and Meta-analysis

BACKGROUND

Patients undergoing hemodialysis or peritoneal dialysis often experience pruritus which is associated with morbidity and mortality. One proposed treatment approach is to target the opioid pathway using either µ-opioid antagonists or κ-opioid agonists.

OBJECTIVE

To review the efficacy of targeting the opioid pathway for pruritus among dialysis patients (uremic pruritus).

DESIGN

Systematic review and meta-analysis.

SETTING/METHODS

The systematic review included randomized controlled and randomized crossover trials identified in the MEDLINE, EMBASE, and Cochrane databases (1990 to June 2014) evaluating the efficacy of µ-opioid antagonists or κ-opioid agonists in the treatment of uremic pruritus.

PATIENTS

Adult (≥18 years) chronic dialysis patients.

MEASUREMENTS

The primary outcome being evaluated was reduction in itch severity measured on a patient-reported visual analog scale (VAS).

RESULTS

Five studies out of 3587 screened articles met the inclusion criteria. Three studies evaluated the efficacy of naltrexone, a µ-opioid antagonist, and 2 studies evaluated the efficacy of nalfurafine, a κ-opioid agonist. Duration of included studies was short, ranging from 2 to 9 weeks.

LIMITATIONS

Due to the heterogeneity in reporting of outcomes, data from the studies evaluating naltrexone could not be pooled. Pooled analysis, using a random effects model, found that use of nalfurafine resulted in a 9.50 mm (95% confidence interval [CI], 6.27-12.74, P < .001) greater reduction of itch severity (measured on a 100-mm VAS) than placebo in the treatment of uremic pruritus.

CONCLUSIONS

Nalfurafine holds some promise with respect to the treatment of uremic pruritus among dialysis patients. However, more long-term randomized controlled trials evaluating the efficacy of therapies targeting the opioid pathway for uremic pruritus are required.

Environmental NO2 and CO Exposure: Ignored Factors Associated with Uremic Pruritus in Patients Undergoing Hemodialysis

Uremic pruritus (UP), also known as chronic kidney disease-associated pruritus, is a common and disabling symptom in patients undergoing maintenance hemodialysis (MHD). The pathogenesis of UP is multifactorial and poorly understood. Outdoor air pollution has well-known effects on the health of patients with allergic diseases through an inflammatory process. Air pollution-induced inflammation could occur in the skin and aggravate skin symptoms such as pruritus or impair epidermal barrier function. To assess the role of air pollutants, and other clinical variables on uremic pruritus (UP) in HD patients, we recruited 866 patients on maintenance HD. We analyzed the following variables for association with UP: average previous 12-month and 24-month background concentrations for nitrogen dioxide (NO2) and carbon monoxide (CO), and suspended particulate matter of <2.5 μm (PM2.5). In a multivariate logistic regression, hemodialysis duration, serum ferritin levels, low-density lipoprotein levels, and environmental NO2/CO levels were positively associated with UP, and serum albumin levels were negatively associated with UP. This cross-sectional study showed that air pollutants such as NO2 and CO might be associated with UP in patients with MHD.

Pruritus in Kidney Disease

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.

Increased Levels of Total p-Cresylsulfate Are Associated with Pruritus in Patients with Chronic Kidney Disease

BACKGROUND

Pruritus is a common and distressing symptom that affects patients with chronic kidney disease (CKD). Indoxyl sulfate (IS) and p-cresylsulfate (PCS) are uremic toxins with similar protein binding, dialytic clearance, and proinflammatory features. Pruritus in CKD may correlate better with uremic toxins than the glomerular filtration rate (GFR), suggesting that uremic toxins either in the central nervous system or peripherally may play an important role in the pathophysiology.

OBJECTIVE

We sought to investigate the potential contribution of serum total IS and PCS to the pathogenesis of pruritus.

METHODS

The serum levels of total IS and PCS concentrations were measured in all patients by using the Ultra Performance LC System. The characteristics of pruritus were assessed using a visual analog scale score and an interview questionnaire.

RESULTS

Among the 320 CKD patients, 35% had pruritus. The patients with pruritus were older and had a higher frequency of diabetes mellitus, higher uric acid, calcium, phosphorus, creatinine, high-sensitivity C-reactive protein, and total IS and PCS levels, and lower albumin concentrations and estimated GFR (eGFR) than those without pruritus. Increasing concentrations of total PCS were independently and significantly associated with pruritus. Multiple logistic regression analysis revealed total PCS as an independent association factor for pruritus, even after full adjustment of known biomarkers. Furthermore, serum total PCS levels were positively associated with calcium, phosphorus, blood urea nitrogen, creatinine, and white blood cell count, and negatively associated with eGFR, hemoglobin, and hematocrit.

CONCLUSION

Our results indicate that total PCS may play a role in the pathogenesis of pruritus.

Comparison of Gabapentin and Ketotifen in Treatment of Uremic Pruritus in Hemodialysis Patients

Objectives:

Uremic pruritus is a common problem in hemodialysis patients. Several treatments have been used for decreasing itching in these patients. Gabapentin and ketotifen are two drugs used for treating uremic patients. The aim of this study was to compare gabapentin and ketotifen in treatment of uremic pruritus in hemodialysis patients.

Methods:

In this double-blind randomized clinical trial, 52 hemodialysis patients with uremic pruritus referred to 5azarTeaching Hospital in Gorgan in 2013 were studied. Patients were randomly assigned to two groups of 26 subjects (groups G and K). In group G, patients treated with gabapentin capsules 100 mg daily for 2 weeks, and in Group K, patients treated with ketotifen 1 mg twice daily for 2 weeks. Before and at the end of study, pruritus severity was determined based on Shiratori’s severity scores. Collected data were analyzed by SPSS-21 statistical software.

Results:

There was no significant different between two groups in the age and sex. After two weeks of treatment, severity of pruritus was significantly reduced in both groups (88.4% in group G vs. 76.9% in group K). Gabapentin compared with ketotifen had a better effect on improving itching in the age group of 30-60 years and in males. 5 patients (19.2%) in both groups suffered from drowsiness and dizziness, but no serious side effects were observed.

Conclusions:

The results showed that gabapentin and ketotifen significantly improved pruritus in hemodialysis patients, and no significant difference was observed between two groups.

Efficacy and safety of gabapentin for uremic pruritus and restless legs syndrome in conservatively managed patients with chronic kidney disease

CONTEXT

Pruritus and restless legs syndrome (RLS) frequently affect patients with chronic kidney disease (CKD) and end-stage kidney disease (ESKD), impacting the quality of life. Gabapentin (1-aminomethyl cyclohexane acetic acid) alleviates these symptoms in hemodialysis (HD) patients, but data are lacking for patients on the conservative pathway.

OBJECTIVES

To determine the safety and effectiveness of gabapentin for pruritus or RLS in conservatively managed patients (n = 34) with CKD and ESKD.

METHODS

This was a single-center retrospective cohort study. We compared dosing and side effects in 34 CKD/ESKD patients with similar patients receiving HD (n = 15).

RESULTS

Forty-four percent of conservatively managed patients complained of RLS and/or pruritus; 18% were excluded for a nonuremic cause of symptom. Thirty-four patients were included in the final analysis. The most common starting daily dose of gabapentin was the equivalent of 50 mg (44.1%) or 100 mg (38.2%) daily, with the median daily dose of 100 mg (range 39-455 mg). Side effects occurred in 47% of patients, with 17% discontinuing gabapentin. Gabapentin reduced symptoms of pruritus (P < 0.001) and RLS (P < 0.05). There was no statistical difference when comparing HD and conservatively managed patients for daily starting dose (P = 0.88), median dose (P = 0.84), and final dose (P = 0.18). Patients conservatively managed were more likely to manifest side effects compared with HD patients (47.1% vs. 14.3%, P = 0.023). Dose was not found to be a factor associated with side effects in univariate analysis.

CONCLUSION

Gabapentin is a viable treatment for conservatively managed CKD and ESKD patients with pruritus and/or RLS, but side effects are common. Gabapentin should be used with caution although higher doses do not appear to be a factor associated with side effects.

Association of systemic diseases with cutaneous dermatosis in elderly population: preliminary observation at a rural tertiary care centre

Introduction:

Aging population is susceptible to many cutaneous and systemic diseases, simultaneously leading to impairment of quality of life in them.

Aim:

To know the association of dermatosis and systemic diseases in geriatric age group.

Materials and Methods:

A retrospective study was carried on patients above 60 years of age who visited the Dermatology OPD at rural tertiary care centre from June 2009 to May 2010. Patients were assessed on a prescribed 30 point proforma.

Results:

Total 457 geriatric patients with dermatosis were registered under the study, of these 203 patients had one or more systemic diseases. Hypertension (70.9%) was the commonest disease, followed by diabetes (32.5%). Eczema was commonest dermatosis in patients with hypertension and generalized pruritus in diabetes.

Conclusion:

Skin diseases cause considerable morbidity in elderly, particularly if associated with other comorbid conditions, so health promotion and education can do much to reduce the risk.

B-type (brain) natriuretic peptide and pruritus in hemodialysis patients

Introduction and objective

While pruritus is a common complication in hemodialysis patients, the pathophysiological mechanisms remain obscure. Recently, B-type (brain) natriuretic peptide (BNP) has been defined as an itch-selective neuropeptide in pruriceptive neurons in mice, and higher serum levels of BNP are frequently observed in hemodialysis patients. The objective of the present study was to evaluate the role of serum BNP in pruritus in patients undergoing hemodialysis.

Patients and methods

The current cross-sectional study was performed on 43 patients undergoing maintenance hemodialysis. A visual analog scale (VAS) measuring the general severity of pruritus (values from 0 to 10, with higher values indicating more severe pruritus) in daytime and at night was self-reported by patients. Each patient’s background and laboratory tests, including serum BNP in the post-hemodialysis period, were collected. The correlation between VAS and clinical parameters was evaluated.

Results

Both daytime and nighttime VAS scores in diabetic patients were significantly less than those in nondiabetic patients. Multiple regression analysis revealed that pruritus in daytime was worsened by serum BNP (β=2.0, t=2.4, P=0.03), calcium (β=4.4, t=5.2, P<0.0001), and β₂-microglobulin (β=2.0, t=3.0, P=0.007), while it was eased by age (β=−2.2, t=−3.2, P=0.0004). Nocturnal pruritus was severe in nondiabetic patients (β=1.7, t=3.8, P=0.0005) and weakened by the total iron binding capacity (β=−2.9, t=−3.1, P=0.004).

Conclusion

It is suggested that a higher level of serum BNP increases the pruritus of hemodialysis patients in daytime and that diabetic patients are less sensitive to itch, especially at nighttime.

Effects of turmeric on uremic pruritus in end stage renal disease patients: a double-blind randomized clinical trial

BACKGROUND

Uremic pruritus as a symptom that affects hemodialysis (HD) patients can decrease the quality of life and increase morbidity in these patients. The aim of this study was to evaluate the effects of turmeric on uremic pruritus in HD patients.

SUBJECTS AND METHODS

This was a double-blind placebo-controlled trial conducted on 100 HD patients suffering from pruritus. Patients (mean age 53.3 ± 15.8 years) were randomized into two groups: turmeric and placebo. The pruritus score and biochemical determinants including high-sensitivity C-reactive protein (hs-CRP) were compared before and at the end of the study between the two groups.

RESULTS

The mean decrease in hs-CRP was significantly higher in the turmeric than the placebo group (-0.8 ± 2.6 vs. 0.4 ± 8.7 mg/l, p = 0.012). Also reduction of pruritus scores was greater in the turmeric than the placebo group (13.6 ± 2.6 vs. 7.2 ± 2.6, p = 0.001). No side effect was observed during the study due to the use of turmeric.

CONCLUSIONS

This study demonstrates the possible efficacy of turmeric in decreasing hs-CRP and uremic pruritus in end stage renal disease patients. Future studies are needed to further evaluate the efficacy and safety of turmeric.

Sericin cream reduces pruritus in hemodialysis patients: a randomized, double-blind, placebo-controlled experimental study

Background

Uremic pruritus (UP) is a significant complication in ESRD patients and substantially impairs their quality of life. UP is considered to be a skin manifestation of chronic inflammation. Because sericin can suppress the release of pro-inflammatory cytokines, the purpose of this study was to investigate the short-term safety and efficacy of sericin cream for treating UP in hemodialysis patients.

Methods

This study used a double-blind design to investigate the effects of random topical administration of sericin cream and cream base (placebo) on either the right or left extremities of hemodialysis patients for 6 weeks. Skin hydration, irritation and pigmentation were evaluated every 2 weeks using Skin Diagnostic SD27. The visual analog scale for itching was also evaluated every 2 weeks, and the Kidney Disease Quality of Life Short Form was performed on the day of each patient’s enrollment and after 6 weeks of treatment.

Results

Fifty dialysis patients were enrolled, 47 of which completed the study. The hydration of the skin of the patients’ extremities increased significantly after administration of sericin cream; significant differences were found between sericin treatment and control after 6 weeks of treatment (p = 0.041 for arms and p = 0.022 for legs, respectively). Moreover, a significant difference was also found in skin irritation between the two treatments (p = 0.013 for arms and p = 0.027 for legs, respectively). At the end of the study, the skin pigmentation level was significantly reduced on both the arms (p = 0.032) and legs (p = 0.021) of the sericin-treated side compared with the side treated with cream base. The mean itching score decreased significantly from moderate to severe at the time of enrollment to mild pruritus after 6 weeks of treatment (p = 0.002). A better quality of life was found in all domains tested although statistically significant differences before and after treatment was found only in the patients’ pain scores, the effect of kidney disease on daily life, sleep quality and symptoms or problems related to kidney disease.

Conclusions

We conclude that sericin cream has a high potential for reducing UP in hemodialysis patients.

The trial registration number of this study is ISRCTN16019033; its public title is “sericin cream reduces pruritus in hemodialysis patients”.

Efficacy of omega-3 fatty acids supplementation in treatment of uremic pruritus in hemodialysis patients: a double-blind randomized controlled trial

BACKGROUND

Uremic pruritus is a common and bothersome complaint among end-stage renal disease which affect between 25% and 60% of this population .But there is no decisive cure for treatment of it. In this study, the effects of omega-3 for treatment of pruritus were investigated in hemodialysis patients.

METHODS

A double-blind randomized study was carried out in the form of placebo-controlled crossover study in four dialysis centers in Tehran, Iran during 2008. At first, 22 hemodialysis patients suffering from pruritus with previous drug resistance were selected. Next, these patients were randomly allocated into two groups of omega-3-placebo (group A) and placebo-omega-3 (group B) .Patients in group A were treated with a 1-gram Fish oil capsule for 20 days, and subsequently, they were treated with placebo for 20 days after a 14-day wash-out period .But the reverse act was done in group B.The pruritus assessment was made quantitatively through Detailed Pruritus Score.

RESULTS

Pruritus was decreased up to 65% from score mean of 20.3 (95% CI: 16.7-23.8) to 6.4 (95% CI: 2.9-9.8) in omega-3 group and the decrease in the placebo group was 15% from score mean of 17.0 (95% CI: 12.4-21.6) to 14.4 (95% CI: 10.5-18.2).So the level of statistical difference was significant (P=0.0001).

DISCUSSION

Omega-3 fatty acids found to be more effective than placebo in decreasing of uremic pruritus. So it seems that Omega-3 fatty acids could be used as an efficient drug for treatment of pruritus in uremic patients.

Effect of sertraline on uremic pruritus improvement in ESRD patients

Background. Although uremic pruritus is a common and upsetting problem of chronic kidney disease, there is no approved treatment for it. This study was undertaken to find the efficiency of sertraline as a possible treatment for uremic pruritus. Methods. 19 ESRD patients under hemodialysis with severe chronic pruritus were randomly selected to participate in this before-after clinical trial. Before and after starting treatment with sertraline, a detailed pruritus history was obtained and pruritus graded by the 30-item inventory of pruritus that patients based on priorities grade allocated to 3 classes. Subjects were treated with sertraline 50 mg oral daily for four months, with monthly assessments of pruritus symptoms. Results. Before treatment with sertraline, the grade of pruritus in 9 (47.4%) patients was moderate and severe in 10 (52.6%) patients. After treatment, grade of pruritus in 11 (57.8%) patients was weak, 6 (31.5%) have moderate and only 2 (10.7%) patients have severe pruritus. Of 10 patients with severe pruritus, 5 (50%) patients experiencing weak pruritus, and 4 (40%) patients have moderate pruritus after treatment. Based on Wilcoxon signed-rank test, the difference between the grade of pruritus before and after treatment with sertraline was significant (P = 0.001). Conclusions. Although no definitive recommendation can be made regarding treatment of uremic pruritus, we found an increased antipruritic effect of sertraline in ESRD patients.

Delusional parasitosis: a rare cause of pruritus in hemodialysis patients

Uremic pruritus is a common symptom in patients undergoing hemodialysis (HD) or peritoneal dialysis, but its exact pathogenesis remains rather unclear. However, severe or "intractable" pruritus may be the manifestation of another underlying disease or disorder other than uremia. Delusional parasitosis, or Ekbom syndrome, is a rare psychiatric disorder characterized by the false conviction of being infested with parasites, and it can be primary, or secondary to several medical and psychiatric disorders. We report 2 elderly HD patients who presented one after another, with delusional parasitosis. At some point in time, the delusional beliefs of the first patient were adopted by the second patient who was waiting to start his HD session on the same bed and HD machine, on a subsequent shift. They were both diagnosed with Ekbom syndrome and described as having monosymptomatic hypochondriac delusion. They were both prescribed antipsychotic medications. During follow-up they admitted feeling better than before; however, they remained concerned about the "insects/parasites."

Evaluating the association between alterations in mineral metabolism and pruritus in hemodialysis patients

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.