Pathways for Diagnosing and Treating CKD-Associated Pruritus: A Narrative Review

Abstract

Purpose of review: Chronic kidney disease (CKD)-associated pruritus is a common, persistent, and distressing itch experienced by patients across the CKD spectrum. Although the disorder is associated with adverse outcomes and poor health-related quality of life, it remains underdiagnosed and undertreated. The purpose of this narrative review is to offer health care providers guidance on how to effectively identify, assess, and treat patients with CKD-associated pruritus, with the goal of reducing symptom burden and improving patient-important outcomes, such as quality of life (QoL).

Sources of information: A panel of nephrologists and researchers from across Canada and the United States was assembled to develop this narrative review based on the best available data, current treatment guidelines, and their clinical experiences.

Methods: A panel of nephrologists who actively care for patients with pruritus receiving dialysis from across Canada was assembled. Two researchers from the United States were also included based on their expertise in the diagnosis and management of CKD-associated pruritus. Throughout Spring 2023, the panel met to discuss key topics in the identification, assessment, and management of CKD-associated pruritus. Panel members subsequently developed summaries of the pertinent information based on the best available data, current treatment guidelines, and added information on their own clinical experiences. In all cases, approval of the article was sought and achieved through discussion.

Key findings: This narrative review provides pragmatic guidance addressing: (1) methods for screening CKD-associated pruritus, (2) assessing severity, (3) management of CKD-associated pruritus, and (4) suggested areas for future research. The panel developed a 3-pillar framework for proactive assessment and severity scoring in CKD-aP: systematic screening for CKD-associated pruritus (pillar 1), assessment of pruritus intensity (pillar 2), and understanding the impact of CKD-associated pruritus on the patient's QoL (pillar 3). Management of CKD-associated pruritus can include ensuring optimization of dialysis adequacy, achieving mineral metabolism targets (ie, calcium, phosphate, and parathyroid hormone). However, treatment of CKD-associated pruritus usually requires additional interventions. Patients, regardless of CKD-associated pruritus severity, should be counseled on adequate skin hydration and other non-pharmacological strategies to reduce pruritus. Antihistamines should be avoided in favor of evidence-based treatments, such as difelikefalin and gabapentin.

Limitations: A formal systematic review (SR) of the literature was not undertaken, although published SRs were reviewed. The possibility for bias based on the experts' own clinical experiences may have occurred. Key takeaways are based on the current available evidence, of which head-to-head clinical trials are lacking.

Funding: This work was funded by an arm's length grant from Otsuka Canada Pharmaceutical Inc. (the importer and distributer of difelikefalin in Canada). LiV Medical Education Agency Inc. provided logistical and editorial support.

Keywords: CKD-associated pruritus treatment; assessment; chronic kidney disease-associated pruritus; dialysis; screening.

Figure 1.

The 3 pillars of proactive assessment and severity scoring in CKD-associated pruritus.^,,,,,, Proposed framework for proactive assessment and severity scoring in CKD-associated pruritus. Pillar 1: systematic screening for CKD-associated pruritus; Pillar 2: assessment of intensity; Pillar 3: understanding the impact on the patient’s QoL. CKD-aP = chronic kidney disease-associated pruritus; ESAS-r = Edmonton Symptom Assessment System-Revised: Renal; PRO = patient-reported outcomes; SADS = Self-assessed Disease Severity; WI-NRS = Worst-Itch Numerical Rating Scale. ^aSeverity scoring ranges have not been validated and are based on limited evidence.

Figure 2.

A modernized approach to CKD-associated pruritus. Proposed algorithm for the management of CKD-associated pruritus. Treatment should be tailored to the individual patient’s goals and needs. CKD-aP = chronic kidney disease-associated pruritus; PTH = parathyroid hormone; SSRI = selective serotonin reuptake inhibitor; UVB = ultraviolet B. ^aTreatment selection dependent on the availability of difelikefalin.