CKD-associated pruritus can have serious consequences. CKD-aP is associated with an increased mortality rate in haemodialysis patients and can also increase healthcare resource utilisation.1–3

Mortality

CKD-aP is associated with an increased risk of mortality. In a study of over 1,700 chronic haemodialysis patients, severe CKD-aP was an independent predictive factor for death even after adjusting for other clinical risk factors (p=0.0084).1

The link between CKD-aP and mortality has also been demonstrated in the DOPPS study where patients with very severe (extremely bothered by itching) CKD-aP were 59% more likely to die within the 18-month follow-up period than patients not bothered by itching. Following adjustment, patients were still 24% more likely to die than those not bothered by itching (adjustments: age, sex, end-stage renal disease vintage, 15 comorbidities, post-dialysis weight, albumin, haemoglobin, phosphorus, and catheter use). Furthermore, patients with very severe (extremely bothered by itching) CKD-aP were 29% more likely to die from cardiovascular events and 44% more likely to die from infection than those not bothered by itching.3

a
Patients extremely bothered by itching had higher rates of all-cause, cardiovascular- and infection-related mortality than patients not bothered by itching.3

Comorbidities associated with CKD-aP have also been linked to increased mortality risk in haemodialysis patients.

An analysis of 18,801 haemodialysis patients from DOPPS found those with moderate to severe (moderately-extremely bothered by itching) CKD-aP were more likely to feel drained and experience sleep disruption (vs. mild/no CKD-aP), which was associated with a 17% higher mortality risk (p<0.0001).4

CKD-aP is associated with depression, which is a well-established risk factor for shortened life expectancy and mortality.5 A meta-analysis of depression of the general population has reported that depression increases the risk of mortality by over 50%, compared to non-depressed individuals.6

Hear from an expert

Watch this video to hear from a leading expert about the underlying consequences of CKD-aP.

More information about the expert

Dr Kieran McCafferty

Dr Kieran McCafferty is a Consultant Nephrologist and Renal Clinical Trial Lead at Barts Health NHS Trust and Senior Lecturer at Queen Mary University London. He is also the Deputy UK NIHR nephrology and Renal Network Lead for the North Thames.

Dr McCafferty’s research interests include haemodialysis, diabetic kidney disease and uraemic cardiovascular disease, however his work focuses on the development and delivery of nephrology clinical trials locally and nationally.

Healthcare resource utilisation

CKD-aP can increase hospitalisation amongst patients undergoing haemodialysis for a number of different reasons. In the DOPPS study, all-cause, cardiovascular-related and infection-related hospitalisation was ~20% more likely in patients suffering with very severe (extremely bothered by itching) CKD-aP vs. those not bothered by itching.3

To assess the impact of CKD-aP on resource utilisation in hospitals, Ramakrishnan K, et al. conducted a detailed retrospective analysis of 38,315 haemodialysis patients. Compared to patients not suffering from itching, patients with very severe (extremely bothered by itching) CKD-aP were reported more likely to use more medication and suffer from increased infections:2

a
Bacteraemia

34% vs. 27%
p<0.00012

a
Septicaemia

8% vs. 6%
p<0.00012

en
Erythropoietin-stimulating
agent

63,405.4 vs. 53,397.1 units
 p<0.00012

en
Intravenous iron

247.6 vs. 237.2 units
p<0.03142

en
Intravenous antibiotics

20.7% vs. 14.1%
p<0.052

Missed dialysis sessions

CKD-aP can also contribute to an increased strain on healthcare resources. Ramakrishnan K, et al. reported that 1,991 patients with very severe (extremely bothered by itching) CKD-aP missed on average 2.6 more dialysis sessions per year compared to patients with no itchiness.2 Furthermore, patients in DOPPS with mild to severe (somewhat-very much bothered by itching) CKD-aP were around 20% more likely to miss 2 or more dialysis sessions over 4 months than those not bothered by itching.3

Early identification and management of CKD-aP through shared team responsibility can ensure the best care for patients.

References & footnotes
References
  1. 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.
  2. 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.
  3. 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.
  4. Pisoni R, Wikström B, Elder S, et al. Pruritus in haemodialysis patients: international results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrol Dial Transplant. (2006);21:3495–3505.
  5. Gilman A, Sucha E, Kingsbury M, et al. Depression and mortality in a longitudinal study: 1952–2011. CMAJ. (2017);189(42):E1304–E1310.
  6. Cuijpers P, Vogelzangs N, Twisk J, et al. Comprehensive meta-analysis of excess mortality in depression in the general community versus patients with specific illnesses. Am J Psychiatry. (2014);171(4):453–62.
  7. Millington G, Collins A, Lovell C, et al. British Association of Dermatologists’ guidelines for the investigation and management of generalised pruritus in adults without an underlying dermatosis, 2018. Br J Dermatol. (2018);178(1):34–60.