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Uraemic pruritus or chronic kidney disease-

associated pruritus(CKD-aP)

Dr Aoife Lowney

Consultant in Palliative Medicine and Renal Supportive Care

Oxford

• Prevalence is underestimated

• Impact is underestimated

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Symptom Burden in 893 Haemodialysis Patients

Lowney et. al JPSM 2015 epub ahead of print

Principle 1

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Not everyone with ESKD and itch has uraemicpruritus or (CKD-aP)

CKD-associated Pruritus

Examine the Skin thoroughly

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Itch Screen

Yosipovitch NEJM 2013; 368:1625-34

True Uraemic Pruritus or (CKD-aP) CKD-associated Pruritus

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Daily itching

Large Discontinuous but symmetric areas

Itch without a dermatosis or rash

Mathur et al Clin J Am Nephrol 2010;5:1410-9

The Butterfly Sign

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Worse at night

Mathur et al Clin J Am Nephrol 2010;5:1410-9

Back and Arms

Heat

Stress

Cold

Physical activity

Showering

Mistik S. J Eur Acad Dermatol Venereol. 2006;20:672-8

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Postulated Mechanisms

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90%10%

Yosipovitch NEJM 2013; 368:1625-34

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Scratching may lead to:

Impetigo

Prurigo

Chronic lichenified dermatitis/

eczema

Management

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Oral antihistamines and systemic steroids are

generally not effective

Combs Seminars in Nephrology 2015; 35:4, 383-391

Spoiler Alert

With the exception of the evidence for gabapentin, there remains considerable uncertainty for effective treatments

Simonsen et al AJKD 2017

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Grade A evidence ≥1 RCT

Gabapentin +/-Pregabalin

9 RCT

N=527

Longest treatment duration 12 weeks

Drowsiness dizziness and somnolence

Overall a statistically significant benefit in favour of intervention arm

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Mast Cell Stabalisers 5 studies n=237

Positive

Topical and oral Cromolyn sodium 2 positive studies (burning and flatulance)

Oral zinc sulfate more effective than placebo

Negative

Hydroxyzine negative study

Nicotinamide negative study

Phototherapy

2 studies significant benefit of broadband UV-B over UV-A

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HD Rx Modification

High flux HD

High permeability HD

Other Systemic Medications Positive

Trials

Montelukast n=80 one trial

Nalfuraline HCL oral n=339 one trial

Thalidomide n=29 one trial

Naltrexone 2x RCTs (The study with shorter duration and fewer participants

concluded that there was a significant effect of naltrexone compared to placebo)

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Other Systemic Medications Negative

Trials

Ondansetron 2 trials

Oral Primrose oil one trial

Cholestyramine ? Significant

Other Topical Medications Trials

Positive GLA (gamma linolineic acid) enriched cream

Capsaicin 2 crossover studies

Pramoxine Hcl 1% (topical anaesthetic caladryl)

Negative Dead sea mineral lotion

Tacrolimus

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Alternative Acupressure 2 positive trials

Homeopathy negative trial

Sertraline 50mg od

Shakiba et al 2012

Grade B Well Designed non-randomised studies

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Approach to Treatment

Combs Seminars in Nephrology 2015; 35:4, 383-391

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Approach to Treatment

Approach to Treatment

Combs Seminars in Nephrology 2015; 35:4, 383-391

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Approach to Treatment

Combs Seminars in Nephrology 2015; 35:4, 383-391

Evening Primrose Oil

Chen YC et al. Am J Kid Dis 2006; 48: 69-76

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supplementing the Gabba-Linolenic Acid (GLA) has an anti-inflammatory/ anti-itch effect

Approach to Treatment

Combs Seminars in Nephrology 2015; 35:4, 383-391

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ZincCapsaicin

Cromolyn sodium topical

Montelulkast

Treat high phosphate

Reactive Perforating Collagenosis

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Reactive Perforating Collagenosis

Acquired – occurs in adulthood, usually in patients with diabetes or chronic renal failure, especially those receiving dialysis

Reactive Perforating Collagenosis

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Abnormal collagen extruding through to the epidermis

Lesions appear in response to superficial trauma such as scratching and are aggravated by cold weather

Reactive Perforating Collagenosis

Isotretinoin

Allopurinol

Doxycycline

Phototherapy

Reactive Perforating Collagenosis

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