Look beneath the surface to the physical and mental repercussions of CKD-associated Pruritus.

CKD-associated Pruritus is much more than just an itch for patients that suffer with it every day.1–5 CKD-associated Pruritus is an important concern for affected patients, as it impacts their quality of life, disturbs sleep and they are more likely to suffer with depression, compared with patients not bothered by itching.

Personal experiences

Watch these videos to hear personal experiences about the underlying effects of CKD-associated
Pruritus from a leading expert’s and a patient’s perspective.

More information about the expert

Prof. Maurizio Gallieni

Prof. Maurizio Gallieni is Associate Professor and Director of the School of Nephrology at the University of Milano, Italy. He graduated and trained at the University of Milano and Verona, Italy, and as a Research Fellow at Washington University in Saint Louis, MO, USA.

Prof. Gallieni’s research interests include; clinical nephrology, CKD and dialysis, CKD-mineral and bone disorders, dialysis access, onco-nephrology, glomerular diseases and simulation training in interventional nephrology. He is Coordinating Editor of the Journal of Vascular Access and has authored 285 publications indexed in PubMed (H index: Scopus:33).

Sleep quality1,2

The DOPPS study has demonstrated the association between CKD-associated Pruritus and significantly reduced sleep quality, in over 20,000 patients with varying degrees of CKD-associated Pruritus severity. DOPPS first demonstrated the link between CKD-associated Pruritus and sleep quality in 2006 and again more recently in a 2020 publication.1,2 The 2020 publication by Sukul N, et al. adjusted their analysis to account for DOPPS phase, country, age, sex, end-stage renal disease vintage, 15 comorbidities, post-dialysis weight, albumin, haemoglobin, phosphorus, and catheter use.2

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Patients with severe (very much and extremely bothered by itching) CKD-associated Pruritus are 2–2.5 times more likely to report suffering from poor sleep quality and 2 times as likely to report feeling washed out or drained than patients not bothered by itching.2

Sleep can also play an important part of general well-being. Disrupted sleep is an important concern for patients with CKD-associated Pruritus and is associated to both physical and mental quality of life outcomes.1 Patients in the DOPPS study with very severe (extremely bothered by itching) CKD-associated Pruritus were 2 to 3 times more likely to have poor sleep quality, be bothered by faintness/dizziness and/or feel washed out or drained than patients not at all bothered by itchy skin.2

Social isolation

CKD-associated Pruritus can make patients avoid social interactions due to the appearance of their skin and the need to scratch which causes frustration and embarrassment, contributing to social isolation.4,5

Social isolation can be a significant risk factor for poor physical health outcomes, depression and unhealthy behaviours that can further impact health (e.g. physical inactivity, poor diet and illicit drug use), regardless of age.6

Could CKD-associated Pruritus be disrupting your patients’ support
network and affecting their health?

Depression

The DOPPS study has also established a link between CKD-associated Pruritus and depression in both 2006 and 2020, in patients undergoing haemodialysis.1,2 In the DOPPS 2006 publication, patients with moderate to severe (moderately-extremely bothered by itching) CKD-associated Pruritus were significantly more likely to be diagnosed with depression (vs. patients with mild/no CKD-associated Pruritus; p≤0.004).1 In the DOPPS 2020 publication, depression was self-assessed by patients using the Centre for Epidemiologic Studies-Depression (CES-D) score derived from the 10-item ‘Boston form’.2

44% of all haemodialysis patients included in DOPPS
reported depressive symptoms.2

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Patients extremely bothered by itching are 2 times more likely to report feeling depressed (CES-D ≥10)  than patients not bothered by itching2

Talk to your CKD patients

Ask if they’ve experienced sleep disruption, social isolation or depression due to pruritus at their next appointment or dialysis session.

Assessing itch severity

Assessing itch intensity and itch-related quality of life is important to understand the burden of CKD-associated Pruritus and the benefits of treatment for patients.9,10

Two useful assessment scales have been developed to help measure itch severity in haemodialysis patient with CKD-associated Pruritus, the worst-itch numerical rating scale (WI-NRS) and the self-assessed disease severity (SADS) scale.

 

The worst-itch numerical rating scale (WI-NRS) assess itch intensity.*9,10

In trials, a reduction of ≥3 points in WI-NRS signified a clinically meaningful improvement in itch severity for patients with moderate-to-severe CKD-associated Pruritus.11

 

Please rate the worst itch you have felt in the previous 24 hours. Select one option:

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Adapted from Phan et al. 2012.10

*WI-NRS is a validated 11-point scale ranging from 0-10 where 0 represents ‘no itching’ and 10 ‘worst itch imaginable’.9,10

Self-assessed disease severity (SADS) assesses the impact of itch on quality of life.9

SADS allows patients to categorise themselves into one of three ‘types’ depending on the severity of their symptoms and signs. This self-categorisation tool can predict intensity and chronicity of pruritus.9

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  • Mild:
  • • I do not generally have scratch marks on my skin
  • • I do not generally have a problem sleeping because of itching
  • • My itching does not generally make me feel agitated or sad

 

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  • Moderate:
  • • I sometimes have scratch marks on my skin
  • • I sometimes have problems sleeping because of itching
  • • My itching can sometimes make me feel agitated or sad

 

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  • Severe:
  • • I often have scratch marks on my skin that may or may not bleed or get infected
  • • I often have a problem sleeping because of itching
  • • My itching often makes me feel agitated or sad

 

Adapted from Mathur et al. 2010.9

References & footnotes
References
  1. Pisoni R, Wikström B, Elder S, et al. Pruritus in haemodialysis patients: international results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). (2006);21:3495–3505.
  2. Sukul N, Karaboyas A, Csomor P, et al. Self-reported pruritus and clinical, dialysis-related, and patient-reported outcomes in hemodialysis patients. Kidney Medicine. (2020);3(1):42–53.e1.
  3. Rayner H, 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);12:2000–2007.
  4. Silverberg J, Kantor R, Dalal P, et al. A comprehensive conceptual model of the experience of chronic itch in adults. AM J Clin Dermatol. (2018);19(5):759–769.
  5. Ibrahim M, Elshahid A, El Baz T, et al. Impact of uraemic pruritus on quality of life among end stage renal disease patients on dialysis. J Clin Diagn Res. (2016);10(3):WC01–WC05.
  6. Hämmig O. Health risks associated with social isolation in general and in young, middle and old age. PLoS One. (2019);14(7):e0219663.
  7. Ramakrishnan K, Bond TC, Claxton A, et al. Clinical characteristics and outcomes of end-stage renal disease patients with self-reported pruritus symptoms. Int J Nephrol Renovasc Dis. (2013);7:1–12.
  8. Narita I, Alchi B, Omori K, et al. Etiology and prognostic significance of severe uremic pruritus in chronic hemodialysis patients. Kidney Int. (2006);69(9):1626–1632.
  9. Mathur VS, Lindberg J, Germain M, et al. A longitudinal study of uremic pruritus in hemodialysis patients. Clin J Am Soc Nephrol. (2010);5(8):1410-1419.
  10.  Phan NQ, Blome C, Fritz F, et al. Assessment of pruritus intensity: prospective study on validity and reliability of the visual analogue scale, numerical rating scale and verbal rating scale in 471 patients with chronic pruritus. Acta Derm Venereol. (2012);92(5):502-507.
  11.  Vernon M, Ständer S, Munera C, et al. Clinically meaningful change in itch intensity scores: An evaluation in patients with chronic kidney disease-associated pruritus. J Am Acad Dermatol. (2021);84(4):1132-1134.