Review Reveals Evidence Gaps in Managing Pruritus in Patients With CKD on Dialysis

A literature review pointed out the limited current research that has been conducted on how to manage pruritus in patients with chronic kidney disease (CKD) treated with dialysis therapy, suggesting that more data is needed to improve symptom burden in these patients.

The review, which was published in Current Opinion in Nephrology and Hypertension, highlighted the possible pathology behind CKD-associated pruritus (CKD-aP) as well as the impact that CKD-aP has on the health-related quality of life (HRQoL) of patients with end-stage kidney disease (ESKD) who are undergoing hemodialysis.

“Despite the clear associations with poorer health outcomes and reduced HRQoL, CKD-aP remains under-appreciated, under-reported and under-diagnosed.…The future of research into symptom management needs to focus on evaluating the relation- ships between multiple symptoms, specific interventions and patient outcomes,” the authors wrote.

Patients with ESKD who are treated with hemodialysis as renal replacement therapy experience a significant symptoms burden over a prolonged period of time. CKD-aP is a frequent burdensome symptom and worsens a patient’s CKD progresses to ESKD, which required hemodialysis to be conducted more frequently. CKD-aP often manifests with debilitating symptoms that have synergistic effects on patients and increases their suffering.

When multiple symptoms occur simultaneously, they are known as a symptom cluster and may share a common biological mechanism that can be targeted with therapies. Therefore, targeting 1 symptom in the cluster with a specific intervention could have an effect on other debilitating symptoms within the same cluster. The authors said that more research on symptom cluster science is needed to clarify the relationship between symptoms and patient outcomes.

“Identification of symptom clusters among patients with ESKD undergoing dialysis may help inform symptom assessment, risk-stratification, and development of patient-centered interventions to reduce symptom burden, thereby reducing the negative impact on patient HRQoL,” the authors noted.

Pruritus is defined as an unpleasant sensation to skin that can result in an itching sensation for over 6 months. Approximately two-thirds of patients undergoing hemodialysis experience CKD-aP, which is often overlooked by health care professionals and underreported by about 17% of patients. CKD-aP may present in bilateral, symmetrical patterns or can be localized to specific areas of the body. It is thought that CKD-aP may result from:

• deposition of uremic toxins in the skin and subcutaneous tissues
• immune system dysregulation and inflammation
• peripheral neuropathy
• alteration in the structure and function of the skin microbiome

Many observational studies have shown the CKD-aP is associated with worsened HRQoL for patients with ESKD treated with hemodialysis. Patients in this population who reported being extremely bother by pruritus during a large epidemiological study had significantly lower mental and physical component scores compared with patients who did not have pruritus.

Data from interventional studies of antipruritic treatments have shown that difelikefalin, mu opioid receptor antagonists, and selective kappa opioid receptor agonists may reduce pruritus intensity, which may also improve HRQoL and sleep quality in patients with CKD-aP.

Additionally, evidence has shown that patients with severe CKD-aP are more likely to withdraw from dialysis therapy compared with those who have mild or moderate CKD-aP, suggesting that pruritus alleviation may increase patient satisfaction with hemodialysis and improve their overall clinical outcomes.

“With new treatment strategies on the horizon, this concept of symptom clusters represents an opportunity not just for the management of CKD-aP, but also for all of those associated symptoms which we know are important to our patients,” said the authors.

Reference

Ahdoot RS, Kalantar-Zadeh K, Burton JO, Lockwood MB. Novel approach to unpleasant symptom clusters surrounding pruritus in patients with chronic kidney disease and on dialysis therapy. Curr Opin Nephrol Hypertens. 2022;31(1):63-71. doi:1 0.1097/MNH.0000000000000752