International Comparisons of Prevalence, Awareness, and Treatment of Pruritus in People on Hemodialysis

Abstract

Background and objectives: Uremic pruritus in patients on hemodialysis is associated with depression, lower quality of life, and mortality. We studied the prevalence, awareness, and treatment of pruritus to assess how well this important condition is currently managed internationally.

Design, setting, participants, & measurements: Data from 35,452 patients on hemodialysis in up to 17 countries from the Dialysis Outcomes and Practice Patterns Study were analyzed to describe pruritus prevalence from 1996 to 2015. Data from 6256 patients and 268 medical directors in 17 countries in 2012-2015 were analyzed to describe predictors, effects, medical directors' awareness, and treatment of pruritus.

Results: Patients very much or extremely bothered by itching declined from 28% in 1996 to 18% in 2015. In 2012-2015, among patients nearly always or always bothered by itching, pruritus had a major effect on work and social life; 18% used no treatment for pruritus, and 17% did not report itching to health care staff. In total, 69% of medical directors underestimated the prevalence of pruritus in their unit. Managing high serum phosphorus and low Kt/V was ranked as the most important intervention, but no relationship was found between these factors and pruritus; 57% of medical directors used oral antihistamines for first-line chronic treatment of pruritus. Gabapentin was used by 45% as first-, second-, or third-line treatment. Nalfurafine was only used in Japan.

Conclusions: The prevalence of pruritus in people on hemodialysis is decreasing but remains underestimated. Large numbers of patients on hemodialysis with severe pruritus do not receive treatment. There is wide variation in the use of unlicensed medications for the treatment of pruritus. These data provide a benchmark for initiatives to improve the management of uremic pruritus.

Multimedia: This article contains multimedia at https://vimeo.com/49458473This article contains multimedia at vimeo.com/49455976.

Keywords: Benchmarking; Cyclohexanecarboxylic Acids; Histamine Antagonists; Phosphorus; Physician Executives; Prevalence; depression; dialysis; gabapentin; gamma-Aminobutyric Acid; hemodialysis; outcomes; quality of life; renal dialysis.

Graphical abstract

Figure 1.

The percentage of patients very much or extremely bothered by itchy skin declined between 1996 and 2015 from 28% to 18%. Question wording: “To what extent were you bothered by itchy skin during the past 4 weeks?” Australia, Belgium, Canada, China, France, the six Gulf Cooperation Council (GCC) countries (Bahrain, Qatar, Kuwait, Oman, Saudi Arabia, and United Arab Emirates), Germany, Italy, Japan, New Zealand, Russia, Spain, Sweden, Turkey, the United Kingdom, and the United States were analyzed. The DOPPS phase 1 collected data from 1996 to 2001, the DOPPS phase 2 collected data from 2002 to 2004, the DOPPS phase 3 collected data from 2005 to 2008, the DOPPS phase 4 collected data from 2009 to 2011, and the DOPPS phase 5 collected data from 2012 to 2015. Data collection in Australia, Belgium, Canada, New Zealand, and Sweden did not begin until phase 2; data collection in China began in phase 4 and started in the GCC countries, Russia, and Turkey in phase 5. Australia, China, France, and New Zealand were excluded in phase 5.

Figure 2.

The percentage of patients at least moderately bothered by itchy skin ranged from 26% in Germany to 48% in the United Kingdom in the DOPPS phase 5 (2012–2015). Results are ranked by the proportion of patients who were moderately to extremely bothered by itchy skin. Question wording: “To what extent were you bothered by itchy skin during the past 4 weeks?” In total, 96% of patients answered this question among patients who completed a patient questionnaire. ANZ, Australia and New Zealand; Bel, Belgium; Can, Canada; Chi, China; GCC, the six Gulf Cooperation Council countries (Bahrain, Qatar, Kuwait, Oman, Saudi Arabia, and United Arab Emirates); Ger, Germany; Ita, Italy; Jpn, Japan; Rus, Russia; Spa, Spain; Swe, Sweden; Tur, Turkey; UK, the United Kingdom; US, the United States.

Figure 3.

There was wide variation between countries in the percentage of patients with pruritus referred to a skin specialist or dermatologist. Data are from 262 medical directors who returned their survey in 2013 (total n=337). Question text: “Among patients with pruritus, estimate the percent of patients you refer to a dermatologist or other specialist.” Bel, Belgium; Can, Canada; GCC, the six Gulf Cooperation Council countries (Bahrain, Qatar, Kuwait, Oman, Saudi Arabia, and United Arab Emirates); Ger, Germany; HD, hemodialysis; Ita, Italy; Jpn, Japan; Rus, Russia; Spa, Spain; Swe, Sweden; Tur, Turkey; UK, the United Kingdom; US, the United States.