Pruritus in Hemodialysis Patients Underestimated, Undertreated
Among hemodialysis patients always or nearly always bothered by itchy skin, 17% did not report their symptoms to a health care provider and 18% used no treatment for the condition.
Severe uremic pruritus among hemodialysis (HD) patients is slowly decreasing in prevalence, but the condition is still underestimated and undertreated, according to researchers.
Using a cohort from the international Dialysis Outcomes and Practice Patterns Study (DOPPS), Hugh C. Rayner, MD, of Birmingham Heartlands Hospital in Birmingham, UK, and colleagues analyzed 1996–2015 data from 35,452 HD patients in DOPPS phases 1–5. To characterize predictors, effects, medical directors' awareness, and treatment of pruritus, the investigators also analyzed 2012–2015 DOPPS data from 6256 patients and 268 medical directors (all nephrologists) in 17 countries.
They found that the proportion of patients who indicated they were very much or extremely bothered by itchy skin decreased from 28% in 1996 to 18% in 2015. The majority of medical directors (65%) of dialysis facilities, however, estimated that less than 5% of their patients suffered from severe pruritus, Dr Rayner and colleagues reported online ahead of print in the Clinical Journal of the American Society of Nephrology. Medical directors underestimated the prevalence of pruritus in 69% of facilities, according to the investigators. In many facilities, where 21% to 50% of patients reported having severe pruritus, only 1% of medical directors estimated the same prevalence of pruritus in their facility. Among patients always or nearly always bothered by itchy skin, 17% did not report their symptoms to a health care provider and 18% used no treatment for pruritus.
Medical directors ranked 5 therapeutic options for patients with severe pruritus in order of importance. The top ranked option was phosphorus control in patients with high serum phosphorus levels, followed by increasing dialysis dose in patients with low Kt/V, increasing prescribed treatment time for those with a short treatment time, lowering parathyroid hormone (PTH) levels in patients with high PTH, and lastly use of prescription medications.
Although managing high serum phosphorus levels and low Kt/V ranked high, the study found no association at all between serum phosphorus or Kt/V and pruritus.
Most medical directors used oral antihistamines for first-line chronic treatment of pruritus, and less than half (45%) used gabapentin as first-, second-, or third-line treatment.
“There is a major opportunity to improve the health and wellbeing of CKD patients through clinicians routinely asking about pruritus and using effective treatments, especially gabapentin,” Dr Rayner commented.
The patients included in the study had answered a survey question that asked: “During the past 4 weeks, to what extent were you bothered by: itchy skin?” Response options were “not bothered at all,” “somewhat bothered,” “moderately bothered,” “very much bothered,” and “extremely bothered.”
Results also showed that about one third of patients bothered by itchy skin were most bothered by it at night, and almost 50% were bothered either at all times of the day or not at any specific time. The study revealed no association between itching and time of dialysis treatment for most patients.
Rayner HC, 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; published online ahead of print. Supplementary Table 6. doi: 10.2215/CJN.03280317