Clinical characteristics and outcomes of end-stage renal disease patients with self-reported pruritus symptoms

Abstract

One of the most common conditions affecting end-stage renal disease (ESRD) patients undergoing hemodialysis (HD) is pruritus. Studies report that itchy and dry skin, symptoms of pruritus, affect 40%-90% of ESRD patients. Yet, in clinical practice the condition is often underdiagnosed resulting in inadequate management and an underappreciated impact on patient outcomes. Two retrospective analyses were conducted: a preliminary analysis of ESRD patients with pruritus symptoms (n=73,124) undergoing HD or peritoneal dialysis at a large dialysis provider and a subsequent detailed analysis of a homogenous subset of patients undergoing in-center HD (n=38,315). The goal was to better understand the clinical burden of pruritus as it relates to patient characteristics, quality of life, medication use, and HD compliance. This population is commonly burdened by multiple comorbidities and related polypharmaceutical management; identifying the relationship of pruritus to these ailments can help guide future research and resource allocation. The detailed analysis confirmed trends observed in the preliminary analysis: 30% reported being "moderately" to "extremely bothered" by itchiness. The HD patient population with the highest severity of self-reported pruritus also had a consistent trend in overall increased resource utilization - higher monthly doses of erythropoietin-stimulating agents (53,397.1 to 63,405.4 units) and intravenous (IV) iron (237.2 to 247.6 units) and higher use of IV antibiotics (14.1% to 20.7%), as well as poorer quality-of-life measures (25-point reductions in Burden of Disease Score and Effects on Daily Life subscales of the Kidney Disease Quality of Life-36 survey). These results highlight the need to better identify and manage ESRD patients impacted by pruritus, as this symptom is associated with negative clinical outcomes and increased resource utilization. Further studies are needed to evaluate the current economic burden of pruritus in ESRD patients and create possible options for an improved pharmacoeconomic profile in this patient population.

Keywords: end-stage renal disease; hemodialysis; itchiness; patient reported outcomes; pruritus.

Figure 1

Kidney disease quality of life assessment: physical and mental component scores by itchiness (preliminary analysis). Note: The total number of patients included in this figure is a subset of patients with complete responses for the physical and mental component of the KDQOL survey; no data imputation was used. Abbreviation: KDQOL, Kidney Disease Quality of Life.

Figure 2

Intravenous antibiotic use by itchiness and type of access (preliminary analysis). Notes: This figure shows intravenous antibiotic use of patients who self-reported itchiness was higher for patients who have a central venous catheter (CVC) than other access types. The P-value represents the difference between a category of itchiness score compared to those who reported being extremely bothered by itchiness (category 5). Overall P-value was not determined for multiple comparisons. The total number of patients included in this figure represent those patients for whom we had complete data regarding dialysis access; no data imputation was used. Abbreviations: AV, arteriovenous; PD, peritoneal dialysis.

Figure 3

EPO administration in dialysis patients by itchiness score (preliminary analysis). Notes: This figure shows the number of dialysis patients (n=68,426) who were receiving EPO (left y axis). The mean monthly dose of EPO (right y axis) shows that among patients receiving EPO, the mean monthly EPO dose rose with increased itchiness. Abbreviations: ANOVA, analysis of variance; EPO, Epogen®.

Figure 4

Monthly erythropoiesis-stimulating agent (ESA) utilization differences by itchiness score (detailed analysis).

Figure 5

Intravenous (IV) iron utilization difference by itchiness score (detailed analysis).