CKD-associated pruritus in haemodialysis: a road map for diagnosis and treatment

Abstract

Of the wide range of symptoms affecting patients with chronic kidney disease (CKD) on haemodialysis, CKD-associated pruritus is one of the most common and burdensome, occurring at moderate-to-severe intensity in 31%-40% of patients, significantly impacting multiple aspects of quality of life, and associated with increased healthcare utilization. Despite the distressing nature of this symptom, clinicians frequently underestimate its prevalence and it is under-reported by patients who may be unaware of the availability of effective treatment options. The identification and management of CKD-associated pruritus should form an essential aspect of patient-centred care; however, patients with CKD may have multiple causes of chronic itch including those of dermatological, systemic, neuropathic and psychogenic origin, and CKD-associated pruritus must be distinguished from these. Together with its highly variable presentation in patients on haemodialysis, the range of potential causes of itch makes differential diagnosis of CKD-associated pruritus challenging. The presence of bilaterally symmetrical and non-dermatomally distributed itching, commonly affecting the back, limbs, chest and head is characteristic of CKD-associated pruritus, although approximately 50% of patients report generalized pruritus. Secondary skin lesions (including excoriation, crusts, impetigo, lichenifications and prurigo also seen in dermatological conditions) may or may not be observed, and xerosis (dry skin) that may exacerbate itching is common. Here, we provide a pragmatic approach to the identification and differential diagnosis of chronic itching in CKD-associated pruritus with the aim of supporting the effective management of this highly distressing symptom in clinical practice.

Keywords: CKD-aP; chronic kidney disease; diagnosis; haemodialysis; pruritus.

Figure 1:

The differential diagnosis of CKD-associated pruritus. *Defined as an unpleasant sensation of the skin leading to the desire to scratch, with symptoms present for more than 6 weeks.

Figure 2:

(A) Typical presentation of pruritus associated with CKD. (B) Typical presentation of pruritus in hepatobiliary disease.

Figure 3:

A treatment algorithm for CKD-associated pruritus (adapted from Agarwal et al. Clin Kidney J, 2023 [17]). *Treatment selection dependent on the availability of difelikefalin. Ca, calcium; P, phosphorus; SSRI, selective serotonin reuptake inhibitor.