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• W3023828622 abstract "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. 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. In the general population, pruritus is often a disturbing, yet fleeting sensation. For patients with advanced CKD or on dialysis, however, pruritus can recur and persist, dramatically affecting quality of life and possibly survival. This condition, termed CKD-aP, also known as uremic pruritus, is common in dialysis patients, and despite over 50 years of research, remains poorly understood and undertreated. Recently, however, advances have been made in the understanding and treatment of chronic itching, including CKD-aP. In this narrative review, we explore the clinical presentation, prevalence, etiology, and treatment of CKD-aP. Our goal is to focus on newer developments in diagnosis and management in order to engender more confidence about treating this condition. Chronic kidney disease–associated pruritus (CKD-aP) is defined as itching directly related to kidney disease, without another comorbid condition to explain itching. CKD-aP has a variable clinical presentation, making its identification difficult.1Mettang T. Kremer A.E. Uremic pruritus.Kidney Int. 2015; 87: 685-691Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar For example, its severity may vary over time from hardly appreciable, to incessant and disturbing; it may be intermittent or persistent; and it may occur anytime in relation to dialysis—before, during, or after.2Gilchrest B.A. Stern R.S. Steinman T.I. et al.Clinical features of pruritus among patients undergoing maintenance hemodialysis.Arch Dermatol. 1982; 118: 154-156Crossref PubMed Google Scholar,3Rayner H.C. Larkina M. Wang M. et al.International comparisons of prevalence, awareness, and treatment of pruritus in people on hemodialysis.Clin J Am Soc Nephrol. 2017; 12: 2000-2007Crossref PubMed Scopus (32) Google Scholar Furthermore, its distribution is variable.4Mathur V.S. Lindberg J. Germain M. et al.A longitudinal study of uremic pruritus in hemodialysis patients.Clin J Am Soc Nephrol. 2010; 5: 1410-1419Crossref PubMed Scopus (111) Google Scholar It is generalized in up to 50% of patients,1Mettang T. Kremer A.E. Uremic pruritus.Kidney Int. 2015; 87: 685-691Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar and when generalized, it is often symmetrical,4Mathur V.S. Lindberg J. Germain M. et al.A longitudinal study of uremic pruritus in hemodialysis patients.Clin J Am Soc Nephrol. 2010; 5: 1410-1419Crossref PubMed Scopus (111) Google Scholar but it can be localized, often occurring on the face, back, and shunt arm only.2Gilchrest B.A. Stern R.S. Steinman T.I. et al.Clinical features of pruritus among patients undergoing maintenance hemodialysis.Arch Dermatol. 1982; 118: 154-156Crossref PubMed Google Scholar,4Mathur V.S. Lindberg J. Germain M. et al.A longitudinal study of uremic pruritus in hemodialysis patients.Clin J Am Soc Nephrol. 2010; 5: 1410-1419Crossref PubMed Scopus (111) Google Scholar Several situations have been known to worsen CKD-aP, including extreme hot or cold, stress, physical activity, and showering.5Combs S.A. Teixeira J.P. Germain M.J. Pruritus in kidney disease.Semin Nephrol. 2015; 35: 383-391Abstract Full Text Full Text PDF PubMed Google Scholar Finally, further complicating the identification of CKD-aP, is the fact that it can occur without any skin manifestations, can coexist with xerosis (dry skin) in 50%–85% of patients,6Szepietowski J.C. Reich A. Schwartz R.A. Uraemic xerosis.Nephrol Dial Transplant. 2004; 19: 2709-2712Crossref PubMed Scopus (0) Google Scholar,7Sukul N. Speyer E. Tu C. et al.Pruritus and patient reported outcomes in non-dialysis CKD.Clin J Am Soc Nephrol. 2019; 14: 673-681Crossref PubMed Scopus (0) Google Scholar and can occur with superimposed complications of itching, including impetigo, crusts, papules, ulcerations, erosions, and prurigo nodularis1Mettang T. Kremer A.E. Uremic pruritus.Kidney Int. 2015; 87: 685-691Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar (Figure 1). Due to this clinical variability, and because CKD-aP is a common condition in dialysis patients, providers should consider any itching in this population related to CKD-aP, unless there is a clear alternative explanation.1Mettang T. Kremer A.E. Uremic pruritus.Kidney Int. 2015; 87: 685-691Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar Potential alternative explanations for itching include comorbid liver, hematologic, and skin conditions, and medications such as opioids.1Mettang T. Kremer A.E. Uremic pruritus.Kidney Int. 2015; 87: 685-691Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar,8Bautista D.M. Wilson S.R. Hoon M.A. Why we scratch an itch: the molecules, cells and circuits of itch.Nat Neurosci. 2014; 17: 175-182Crossref PubMed Scopus (175) Google Scholar There are no universally accepted methods to measure CKD-aP, and this has led to a wide range of prevalence estimates. Currently used scales can be divided into those that measure severity, multidimensional scales that measure several itch characteristics, and scales that measure the impact of itching on quality of life (QOL). Four scales are commonly used to measure itching severity: the visual analog scale (VAS), the numeric rating scale (NRS), the verbal rating scale (VRS), and the Kidney Disease Quality of Life-Short Form (KDQOL-SF). The VAS is the most commonly used scale to measure CKD-aP severity.9Pereira M.P. Stander S. Assessment of severity and burden of pruritus.Allergol Int. 2017; 66: 3-7Abstract Full Text Full Text PDF PubMed Google Scholar Originally developed to evaluate pain, the VAS has been adapted to measure itching. It depicts a horizontal or vertical line, generally 10 cm in length, in which the extreme left represents no itching and the extreme right the worst itching imaginable. Similarly, the NRS grades itching severity on a numerical scale from 0 to 10, and the VRS includes 4 itching severities: no, low, moderate, and severe.10Phan N.Q. Blome C. Fritz F. et al.Assessment of pruritus intensity: prospective study on validity and reliability of the visual analogue scale, numerical rating scale and verbal rating scale in 471 patients with chronic pruritus.Acta Derm Venereol. 2012; 92: 502-507Crossref PubMed Scopus (239) Google Scholar The 24-hour worst itching intensity NRS is a validated version of the NRS in which patients grade the overall severity of the worst level of their itching in the previous 24 hours.11Naegeli A.N. Flood E. Tucker J. et al.The Worst Itch Numeric Rating Scale for patients with moderate to severe plaque psoriasis or psoriatic arthritis.Int J Dermatol. 2015; 54: 715-722Crossref PubMed Google Scholar The VAS, NRS, and VRS have similar reliability and validity.10Phan N.Q. Blome C. Fritz F. et al.Assessment of pruritus intensity: prospective study on validity and reliability of the visual analogue scale, numerical rating scale and verbal rating scale in 471 patients with chronic pruritus.Acta Derm Venereol. 2012; 92: 502-507Crossref PubMed Scopus (239) Google Scholar The KDQOL-SF includes 43 kidney disease–specific questions and the 36-item short-form health survey (SF-36).12Hays R.D. Kallich J.D. Mapes D.L. et al.Development of the kidney disease quality of life (KDQOL) instrument.Qual Life Res. 1994; 3: 329-338Crossref PubMed Scopus (705) Google Scholar Originally designed to test QOL in dialysis patients, this survey includes 1 question (question 20) about itching severity: “During the past 4 weeks, to what extent were you bothered by: itchy skin?” Choices include, “(1) not at all bothered, (2) somewhat bothered, (3) moderately bothered, (4) very much bothered, and (5) extremely bothered.” This question has been the basis of the largest international studies of CKD-aP prevalence in dialysis.3Rayner H.C. Larkina M. Wang M. et al.International comparisons of prevalence, awareness, and treatment of pruritus in people on hemodialysis.Clin J Am Soc Nephrol. 2017; 12: 2000-2007Crossref PubMed Scopus (32) Google Scholar,13Pisoni R.L. Wikstrom B. Elder S.J. et al.Pruritus in haemodialysis patients: international results from the Dialysis Outcomes and Practice Patterns Study (DOPPS).Nephrol Dial Transplant. 2006; 21: 3495-3505Crossref PubMed Scopus (281) Google Scholar The most commonly used multidimensional itching scales are the 5-D itching scale and the itching severity scale (ISS).14Elman S. Hynan L.S. Gabriel V. et al.The 5-D itch scale: a new measure of pruritus.Br J Dermatol. 2010; 162: 587-593Crossref PubMed Scopus (0) Google Scholar,15Majeski C.J. Johnson J.A. Davison S.N. et al.Itch severity scale: a self-report instrument for the measurement of pruritus severity.Br J Dermatol. 2007; 156: 667-673Crossref PubMed Scopus (77) Google Scholar The 5-D itching scale evaluates intensity of itching, itching duration, itching pattern, and its effect on QOL. This scale is reliable, correlates well with the VAS, and validly measures changes in pruritus over time.14Elman S. Hynan L.S. Gabriel V. et al.The 5-D itch scale: a new measure of pruritus.Br J Dermatol. 2010; 162: 587-593Crossref PubMed Scopus (0) Google Scholar The ISS measures duration, frequency, pattern, intensity, treatment, symptoms, sensation, and effect of itching on QOL. It is a valid and reliable measure of itching.15Majeski C.J. Johnson J.A. Davison S.N. et al.Itch severity scale: a self-report instrument for the measurement of pruritus severity.Br J Dermatol. 2007; 156: 667-673Crossref PubMed Scopus (77) Google Scholar The dermatology QOL index (DLQI) and the Skindex have been developed and validated to measure the impact of skin disease on QOL.16Finlay A.Y. Khan G.K. Dermatology Life Quality Index (DLQI)—a simple practical measure for routine clinical use.Clin Exp Dermatol. 1994; 19: 210-216Crossref PubMed Scopus (2842) Google Scholar,17Chren M.M. Lasek R.J. Quinn L.M. et al.Skindex, a quality-of-life measure for patients with skin disease: reliability, validity, and responsiveness.J Invest Dermatol. 1996; 107: 707-713Abstract Full Text PDF PubMed Google Scholar The DLQI contains 10 questions that measure the effects of itching on symptoms/feelings, daily activities, leisure, work/school, personal relationships, and treatment.16Finlay A.Y. Khan G.K. Dermatology Life Quality Index (DLQI)—a simple practical measure for routine clinical use.Clin Exp Dermatol. 1994; 19: 210-216Crossref PubMed Scopus (2842) Google Scholar The Skindex contains 61 questions that measure the effects of skin disease on QOL, including psychosocial effects that are cognitive, social, or emotional, and physical effects related to discomfort or limitations.17Chren M.M. Lasek R.J. Quinn L.M. et al.Skindex, a quality-of-life measure for patients with skin disease: reliability, validity, and responsiveness.J Invest Dermatol. 1996; 107: 707-713Abstract Full Text PDF PubMed Google Scholar The original scale was found to be internally reliable, reproducible, and valid.17Chren M.M. Lasek R.J. Quinn L.M. et al.Skindex, a quality-of-life measure for patients with skin disease: reliability, validity, and responsiveness.J Invest Dermatol. 1996; 107: 707-713Abstract Full Text PDF PubMed Google Scholar A shorter version has been used in studies of CKD-aP outcomes.4Mathur V.S. Lindberg J. Germain M. et al.A longitudinal study of uremic pruritus in hemodialysis patients.Clin J Am Soc Nephrol. 2010; 5: 1410-1419Crossref PubMed Scopus (111) Google Scholar,18Chren M.M. The Skindex instruments to measure the effects of skin disease on quality of life.Dermatol Clin. 2012; 30: 231-236, xiiiAbstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar,19Fishbane S. Jamal A. Munera C. et al.A phase 3 trial of difelikefalin in hemodialysis patients with pruritus.N Engl J Med. 2020; 382: 222-232Crossref PubMed Scopus (18) Google Scholar One of the first studies to measure CKD-aP in dialysis patients was published almost 50 years ago.20Young Jr., A.W. Sweeney E.W. David D.S. et al.Dermatologic evaluation of pruritus in patients on hemodialysis.NY State J Med. 1973; 73: 2670-2674PubMed Google Scholar At that time, the prevalence in 36 hemodialysis (HD) patients was 86%.20Young Jr., A.W. Sweeney E.W. David D.S. et al.Dermatologic evaluation of pruritus in patients on hemodialysis.NY State J Med. 1973; 73: 2670-2674PubMed Google Scholar Since then, the prevalence of this condition in HD patients has decreased to approximately 40%.3Rayner H.C. Larkina M. Wang M. et al.International comparisons of prevalence, awareness, and treatment of pruritus in people on hemodialysis.Clin J Am Soc Nephrol. 2017; 12: 2000-2007Crossref PubMed Scopus (32) Google Scholar Recent large studies defining prevalence rates of CKD-aP in HD, peritoneal dialysis (PD), and CKD patients are summarized in Table 1. To date, the largest studies of CKD-aP prevalence have been from the Dialysis Outcomes and Practice Patterns Study (DOPPS).Table 1Select studies examining the prevalence, characteristics, and outcomes of chronic kidney disease–associated pruritus (CKD-aP)Author, yrStudy design and populationItching and outcome toolsPrevalenceCharacteristicsOutcomesHemodialysisRayner et al., 20173Rayner H.C. Larkina M. Wang M. et al.International comparisons of prevalence, awareness, and treatment of pruritus in people on hemodialysis.Clin J Am Soc Nephrol. 2017; 12: 2000-2007Crossref PubMed Scopus (32) Google Scholar35,452 HD patients from 17 countries from DOPPS I–V (1996–2015); 6256 HD patients from DOPPS V (2012–2015); 268 medical directorsItching severity: VRS (5-grade); QOL: Skindex-10 scale (6-grade); intervention by medical directors: first, second, and third line for acute and chronic use74% with some itch, 46% moderate–extreme (DOPPS I); decreased to 69% some and, 37% moderate–extreme (DOPPS V)Higher AOR of moderate to severe pruritus with older age, higher CRP, low serum albumin, presence of hepatitis B or C;No association with Phos, Ca, Ca-Phos product, PTH, Kt/V, or hemodiafiltrationPatients very much or extremely bothered by, also bothered by dry skin (84%), restless sleep (60%)Medical directors underestimated pruritus in 69% of facilities57% of medical directors used oral antihistamines for first-line treatmentGabapentin was used by 45% as first, second, or third treatmentRamakrish-nan et al., 201321Ramakrishnan K. Bond T.C. Claxton A. et al.Clinical characteristics and outcomes of end-stage renal disease patients with self-reported pruritus symptoms.Int J Nephrol Renovasc Dis. 2013; 7: 1-12PubMed Google Scholar71,000 US HD and PD patientsItching severity: VRS scale from the KDQOL survey (5-grade);QOL: SF-1260% “some itching”;14.5% “very much or extremely bothered”Itching associated with younger, female, DM, CAD, COPD, liver disease, dialysis vintage, BMI; lower Hgb and albumin; higher Ca, Phos, PTH, ferritinItching severity associated with(i) Decrease in QOL(ii) Increased medication use: (i.v. antibiotic, i.v. ESA, and i.v. iron)(iii) Increase in missed HD sessionsKimata et al., 201422Kimata N. Fuller D.S. Saito A. et al.Pruritus in hemodialysis patients: results from the Japanese Dialysis Outcomes and Practice Patterns Study (JDOPPS).Hemodial Int. 2014; 18: 657-667Crossref PubMed Scopus (49) Google Scholar6480 Japanese HD patients from JDOPPS (1996–2008); 60–65 facilities followed for a median of 1.9 yrItching severity:VRS (5-grade);QOL: SF-36, SF-12;Sleep quality: self-report: “very bad” or “fairly bad”44% of patients experienced moderate to severe itchingHigher AOR of moderate to extreme pruritus: older, male, smoking, HTN, AVG, ascites, hepatitis C; higher Ca, Phos, or PTH levels; lower albumin, aluminum levelsLower odds: ESRD ≤ 1 yrPatients with moderate to extreme pruritus compared to no/mild pruritus(i) Feel drained (AOR = 2.2–5.8)(ii) Poor sleep (AOR = 1.9–3.7)(iii) Lower QOL mental and physical composite scores (adjusted)Pruritus in HD patients associated with a 23% higher adjusted mortality (P = 0.09)Pisoni et al., 200613Pisoni R.L. Wikstrom B. Elder S.J. et al.Pruritus in haemodialysis patients: international results from the Dialysis Outcomes and Practice Patterns Study (DOPPS).Nephrol Dial Transplant. 2006; 21: 3495-3505Crossref PubMed Scopus (281) Google Scholar18,801 adult HD patients from 308 dialysis centers in DOPPS I (1996–2001) and 322 centers in DOPPS II (2002–2004)Itching: VRS (5-grade);Sleep quality: 3 self-report questions;QOL: SF-36 or SF-12Moderate to extreme pruritus in 42% of patients in DOPPS II and 45% in DOPPS IHigher AOR of moderate to extreme pruritus: male, lung disease, CHF, neuro disease, ascites, hepatitis C; higher Ca, Phos, WBC; lower albuminLower adjusted odds: high serum ferritin, ESRD vintage ≤3 mo or lived with ESRD >10 yrPatients with moderate to extreme pruritus compared to none(i) 13% higher adjusted mortality risk in DOPPs I, 21% higher in DOPPS II(ii) Feeling drained (AOR = 2.3–5.3)(iii) Depression (AOR = 1.3–1.7)(iv) Poor sleep (AOR = 1.4–4)(v) Worse QOL. No itch had MCS/PCS scores 8.6/6.4 points higher than those with extreme itchinessNarita et al., 200623Narita I. Alchi B. Omori K. et al.Etiology and prognostic significance of severe uremic pruritus in chronic hemodialysis patients.Kidney Int. 2006; 69: 1626-1632Abstract Full Text Full Text PDF PubMed Scopus (181) Google Scholar1773 adult Japanese HD patients followed for 2 yr or until deathItching: VAS: No/mild = <4; moderate = 4–6.9; severe = ≥7; Frequency (graded 1–5);Sleep disturbance (graded 1–4)No/mild = 19.5%; moderate = 27.9%; severe VAS = 25.5%Male, BUN, β2-microglobulin; higher Ca and Phos were risk factors for severe pruritus (adjusted)Low Ca and PTH associated with reduced riskSevere pruritus is an independent predictor of death (HR = 1.60).In patients with severe pruritus, more than 70% complained of grade 2–4 sleep disturbance (unadjusted).Pre-dialysis CKDSukul et al.,20197Sukul N. Speyer E. Tu C. et al.Pruritus and patient reported outcomes in non-dialysis CKD.Clin J Am Soc Nephrol. 2019; 14: 673-681Crossref PubMed Scopus (0) Google Scholar3780 patients with CKD 3–5 from the US, Brazil, and FranceItching severity: NRS (5-grade), PCS score;QOL: SF-36;Depression: CES-D short form, MCS score24% with moderate to severe itchingHigher APR of moderate to extreme pruritus: older age, female sex, stage-5 CKD, lung disease, DM, physician-diagnosed depression; higher Phos and lower Hgb; Lower l with male sexPatients with extreme pruritus compared to none(i) Lower QOL—7.6- and 6.2-point decrease in PCS and MCS scores,(ii) More depression (APR = 2.55),(iii) More restless sleep (APR = 2.1)Peritoneal dialysisMin et al., 201624Min J.W. Kim S.H. Kim Y.O. et al.Comparison of uremic pruritus between patients undergoing hemodialysis and peritoneal dialysis.Kidney Res Clin Pract. 2016; 35: 107-113Crossref PubMed Google Scholar425 HD and 223 PD patients from KoreaItching intensity: VAS, modified Pauli-Magnus scale25Pauli-Magnus C. Mikus G. Alscher D.M. et al.Naltrexone does not relieve uremic pruritus: results of a randomized, double-blind, placebo-controlled crossover study.J Am Soc Nephrol. 2000; 11: 514-519PubMed Google ScholarPD > HD— 62.6% vs. 48.3% with VAS ≥ 1Pruritus negatively correlated with Kt/V and positively correlated with dialysis vintage, BP, cholesterol (adjusted)PD associated with higher odds of pruritus than HD (AOR = 1.76)Pruritus associated with higher BMI (AOR = 1.06)Li et al.,201526Li J. Guo Q. Lin J. et al.Prevalence and associated factors of uraemic pruritus in continuous ambulatory peritoneal dialysis patients.Intern Med. 2015; 54: 2827-2833Crossref PubMed Scopus (4) Google Scholar362 Chinese PD patientsItching intensity: VAS (No = 0, mild–moderate = 1–5, severe >5)Sleep quality: PSQIDepression: BDIQOL: SF-36No = 34.8%; Mild–moderate = 52.5%; severe = 12.7%Pruritus associated with dialysis vintage (AOR = 1.04) and higher PTH (AOR = 1.3)Severe pruritus associated with higher(i) PSQI, BDI (adjusted)(ii) Lower SF-36 PCS scores (unadjusted)AOR, adjusted odds ratio; APR, adjusted prevalence ratio; AVG, arteriovenous graft; BDI, Beck’s Depression Inventory; BMI, body mass index; BP, blood pressure; BUN, blood urea nitrogen; Ca, calcium; CAD, coronary artery disease; CES-D, Center for Epidemiologic Studies Depression Scale; CHF, congestive heart failure; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; CRP, C-reactive protein; DM, diabetes mellitus; DOPPS, Dialysis Outcomes and Practice Patterns Study; ESA, erythropoiesis-stimulating agents; ESRD, end-stage renal disease; HD, hemodialysis; Hgb, hemoglobin; JDOPPS, Japanese Dialysis Outcomes and Practice Patterns Study; KDQOL, Kidney Disease quality of life; HTN, hypertension; MCS, Mental Component Summary; MCS; Mental Component Summary: NRS, Numeric Rating Scale; PCS, Physical Component Summary; PD, peritoneal dialysis; PCS, Physical Component Summary; Phos, phosphorus; PSQI, Pittsburgh Sleep Quality Index; PTH, parathyroid hormone; QOL, quality of life; SF-12, 12-item short-form health survey; SF-36, 36-item short-form health survey; VAS, visual analog scale; VRS, verbal rating scale; WBC, white blood cell. Open table in a new tab AOR, adjusted odds ratio; APR, adjusted prevalence ratio; AVG, arteriovenous graft; BDI, Beck’s Depression Inventory; BMI, body mass index; BP, blood pressure; BUN, blood urea nitrogen; Ca, calcium; CAD, coronary artery disease; CES-D, Center for Epidemiologic Studies Depression Scale; CHF, congestive heart failure; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; CRP, C-reactive protein; DM, diabetes mellitus; DOPPS, Dialysis Outcomes and Practice Patterns Study; ESA, erythropoiesis-stimulating agents; ESRD, end-stage renal disease; HD, hemodialysis; Hgb, hemoglobin; JDOPPS, Japanese Dialysis Outcomes and Practice Patterns Study; KDQOL, Kidney Disease quality of life; HTN, hypertension; MCS, Mental Component Summary; MCS; Mental Component Summary: NRS, Numeric Rating Scale; PCS, Physical Component Summary; PD, peritoneal dialysis; PCS, Physical Component Summary; Phos, phosphorus; PSQI, Pittsburgh Sleep Quality Index; PTH, parathyroid hormone; QOL, quality of life; SF-12, 12-item short-form health survey; SF-36, 36-item short-form health survey; VAS, visual analog scale; VRS, verbal rating scale; WBC, white blood cell. DOPPS is an international cohort study of adult dialysis patients designed to inform providers of practices that lead to the best outcomes.27Pisoni R.L. Gillespie B.W. Dickinson D.M. et al.The Dialysis Outcomes and Practice Patterns Study (DOPPS): design, data elements, and methodology.Am J Kidney Dis. 2004; 44: 7-15Abstract Full Text Full Text PDF PubMed Scopus (202) Google Scholar Study patients are enrolled randomly from select multinational dialysis units. Collected data include demographics, diabetes as cause of ESRD, mortality data, the KDQOL-SF, the Center for Epidemiologic Studies Short Depression survey (CES-D-10), a patient satisfaction measure, and a medical director survey. Since its initiation in 1996, there have been 6 phases of the study. In the first phase (1996–2001), 17,034 patients from 308 randomly selected HD units from 7 countries participated. In phase 5 (2012–2015), 36,743 patients from 508 randomly selected HD units from 21 countries participated. In the second year of the phase V study, questions from the Skindex-10 that measured the psychosocial effects of itching were included. In 2013, medical directors were asked to estimate CKD-aP prevalence in their units, and to describe how they treat CKD-aP. In phase 5 of DOPPS, 6256 of 8621 (73%) HD patients answered question 20 of the KDQOL-SF survey related to itching. A total of 37% were at least moderately bothered by itching, and 18% were very much or extremely bothered by itching.3Rayner H.C. Larkina M. Wang M. et al.International comparisons of prevalence, awareness, and treatment of pruritus in people on hemodialysis.Clin J Am Soc Nephrol. 2017; 12: 2000-2007Crossref PubMed Scopus (32) Google Scholar As was seen in previous phases of the study,13Pisoni R.L. Wikstrom B. Elder S.J. et al.Pruritus in haemodialysis patients: international results from the Dialysis Outcomes and Practice Patterns Study (DOPPS).Nephrol Dial Transplant. 2006; 21: 3495-3505Crossref PubMed Scopus (281) Google Scholar these percentages were similar across 19 countries. The highest percentage of patients at least moderately bothered by itching was in the UK (48%), and the lowest was in Germany (26%). These prevalence rates have decreased steadily since DOPPS I (1996–2001) when 46% of HD patients were at least moderately bothered by itching and 28% were very much or extremely bothered by itching.3Rayner H.C. Larkina M. Wang M. et al.International comparisons of prevalence, awareness, and treatment of pruritus in people on hemodialysis.Clin J Am Soc Nephrol. 2017; 12: 2000-2007Crossref PubMed Scopus (32) Google Scholar Similar prevalence rates have been found in 2 other large HD cohorts.21Ramakrishnan K. Bond T.C. Claxton A. et al.Clinical characteristics and outcomes of end-stage renal disease patients with self-reported pruritus symptoms.Int J Nephrol Renovasc Dis. 2013; 7: 1-12PubMed Google Scholar,22Kimata N. Fuller D.S. Saito A. et al.Pruritus in hemodialysis patients: results from the Japanese Dialysis Outcomes and Practice Patterns Study (JDOPPS).Hemodial Int. 2014; 18: 657-667Crossref PubMed Scopus (49) Google Scholar An analysis of 6480 Japanese HD patients found that the prevalence of moderate to severe pruritus, using a modified VRS scale, was 44%.22Kimata N. Fuller D.S. Saito A. et al.Pruritus in hemodialysis patients: results from the Japanese Dialysis Outcomes and Practice Patterns Study (JDOPPS).Hemodial Int. 2014; 18: 657-667Crossref PubMed Scopus (49) Google Scholar A study of 38,315 US HD patients (approximately 40% African American) found that the prevalence of at least moderate itching, using question 20 of the KDQOL SF-36 survey, was 30%, and 14.5% were very much or extremely bothered by itching.21Ramakrishnan K. Bond T.C. Claxton A. et al.Clinical characteristics and outcomes of end-stage renal disease patients with self-reported pruritus symptoms.Int J Nephrol Renovasc Dis. 2013; 7: 1-12PubMed Google Scholar Few studies have reported on the prevalence of CKD-aP in PD patients. In a study of 362 Chinese PD patients, the prevalence of mild to moderate pruritus was 52.5%, and severe pruritus 12.7%.26Li J. Guo Q. Lin J. et al.Prevalence and associated factors of uraemic pruritus in continuous ambulatory peritoneal dialysis patients.Intern Med. 2015; 54: 2827-2833Crossref PubMed Scopus (4) Google Scholar In a study of 223 patients on PD and 425 HD patients from Korea, the prevalence of at least mild pruritus was 62.5% in HD patients and 48.3% in patients on PD.24Min J.W. Kim S.H. Kim Y.O. et al.Comparison of uremic pruritus between patients undergoing hemodialysis and peritoneal dialysis.Kidney Res Clin Pract. 2016; 35: 107-113Crossref PubMed Google Scholar A meta-analysis of 6 cross-sectional prevalence studies (2 PD-only and 4 mixed HD and PD) showed a prevalence of CKD-aP of 56% (95% CI, 44%–68%)28Hu X. Sang Y. Yang M. et al.Prevalence of chronic kidney disease-associated pruritus among adult dialysis patients: a meta-analysis of cross-sectional studies.Medicine (Baltimore). 2018; 97e10633Crossref PubMed Scopus (0) Google Scholar; however, the severity of this pruritus was not reported. Studies comparing CKD-aP prevalence rates in HD and PD patients have yielded mixed results. Two studies found no difference in pruritus rates29Mettang T. Fritz P. Weber J. et al.Uremic pruritus in patients on hemodialysis or continuous ambulatory peritoneal dialysis (CAPD). The role of plasma histamine and skin mast cells.Clin Nephrol. 1990; 34: 136-141PubMed Google Scholar,30Tessari G. Dalle Vedove C. Loschiavo C. et al.The impact of pruritus on the quality of lif" @default.
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• W3023828622 date "2020-09-01" @default.
• W3023828622 modified "2023-10-14" @default.
• W3023828622 title "CKD-Associated Pruritus: New Insights Into Diagnosis, Pathogenesis, and Management" @default.
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