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The Experience of Pruritus in CKD

How distress from itchy skin impacts patient health and quality of life

Recent findings from the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps) advance our knowledge of the patient experience of pruritus, or itchy skin, early in the lifecycle of kidney disease.

    Nidhi Sukul, MD

Nidhi Sukul, MD

The study, which appears in the April 2019 issue of the Clinical Journal of the American Society of Nephrology (CJASN), is the work of an Arbor Research Collaborative for Health/CKDopps team led by Nidhi Sukul, MD (University of Michigan). This study is the first of its kind to evaluate the prevalence of pruritus and its association with patient-reported outcomes in such a large, international sample of patients with non-dialysis chronic kidney disease (CKD).

The major findings of this work include:

  • A 24% prevalence of moderate-to-extreme pruritus among patients with non-dialysis CKD in Brazil, France, and the United States (US), ranging from nearly 23% in Brazil to 29% in the US, with higher prevalence in later stages of CKD.
     
  • Patient characteristics associated with more severe pruritus included patient age ≥70, female sex, and advanced kidney disease.
     
  • Comorbid lung disease, diabetes, and physician-diagnosed depression were also associated with moderate-to-extreme pruritus.
     
  • More severe itching was linked to increasingly poor mental and physical health, self-reported depressive symptoms, and self-reported restless sleep. Patients with extreme pruritus had more than twice the prevalence of self-reported restless sleep when compared with those without.

Some findings are similar to those among patients receiving hemodialysis. The association of diabetes with pruritus among patients with kidney disease may be related to the peripheral neuropathy linking both disorders.

We don’t yet fully understand how uremic pruritus develops and progresses, but it is possible that inflammation or low hemoglobin levels may play roles. It is conceivable that the higher prevalence of depression seen in patients with more severe pruritus could be related to the restless sleep and fatigue that worsen with pruritus, as disturbed sleep has a known relationship with impaired quality of life, depression, and mortality.

These findings underscore the importance of identifying CKD patients who suffer from pruritus in order to potentially provide relief and improve quality of life. This study lays the groundwork for future and prospective studies of pruritus severity across the course of kidney disease.

“One of the main goals of managing chronic disease is alleviating symptoms; however, this is only possible when we are aware of the suffering patients endure,” said Dr. Sukul. “This research gives us a uniquely international look at how important it is to ask our patients with chronic kidney disease if and how they are affected by pruritus. Some drugs have been shown to largely improve pruritus-related symptoms for a substantial percentage of patients, but even if we do not have a universally effective treatment for pruritus, recognizing that pruritus ails our patients and affects their quality of life will make them feel heard and enhance the patient-physician relationship in discussing approaches that may help provide relief from pruritus.”

Visual abstract of the article

CITATION:Sukul N, Speyer E, Tu C, Bieber BA, Li Y, Lopes AA, Asahi K, Mariani L, Laville M, Rayner HC, Stengel B, Robinson BM, Pisoni RL, on behalf of CKDopps and CKD-REIN investigators. Pruritus and Patient Reported Outcomes in Non-Dialysis CKD. CJASN Apr 2019, CJN.09600818; DOI: 10.2215/CJN.09600818
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