CKD-associated Pruritus (formerly referred to as uremic pruritus) can have serious consequences, and has been associated with missed dialysis sessions, an increased mortality rate in haemodialysis patients and greater healthcare resource utilisation.1–3
Mortality
CKD-associated Pruritus is associated with an increased risk of mortality. In a study of over 1,700 chronic haemodialysis patients, severe CKD-associated Pruritus was an independent predictive factor for death even after adjusting for other clinical risk factors (p=0.0084).1
The link between CKD-associated Pruritus and mortality has also been demonstrated in the DOPPS study where patients with very severe (extremely bothered by itching) CKD-associated Pruritus 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-associated Pruritus were 29% more likely to die from cardiovascular events and 44% more likely to die from infection than those not bothered by itching.3
CKD-associated Pruritus is often described as painful, with areas itching for extended periods – sometimes constantly.
Eckhard’s story
Eckhard feels that no one cares about how CKD-aP has caused him constant pain and trouble sleeping. Yet he remains hopeful for a solution in the future.
Comorbidities associated with CKD-associated Pruritus 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-associated Pruritus were more likely to feel drained and experience sleep disruption (vs. mild/no CKD-associated Pruritus), which was associated with a 17% higher mortality risk (p<0.0001).4
CKD-associated Pruritus 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
Watch this video to hear from a leading expert about the underlying consequences of CKD-associated Pruritus.
Patients suffering from CKD-associated Pruritus may experience far-reaching, adverse impacts on their quality of life, with a burden placed upon healthcare systems and providers.
How does CKD-aP impact patients’ lives?
Dr. Rastogi explains how CKD-aP is more than just an itch, with impacts on physical and psychological wellbeing through its association with depressive symptoms, poor sleep quality, increased hospitalisations, missed dialysis sessions and even increased mortality, as demonstrated in DOPPS.
Dr. Anjay Rastogi, MD, PhD
Dr. Rastogi is a Professor and Clinical Chief of Nephrology at the David Geffen School of Medicine at UCLA, Los Angeles, California.
As a director of the Nephrology Clinical Research Program, Dr. Rastogi takes pride in providing the best comprehensive and integrated care to patients and their families.
Healthcare resource utilisation
CKD-associated Pruritus 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-associated Pruritus vs. those not bothered by itching.3
To assess the impact of CKD-associated Pruritus 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-associated Pruritus were reported more likely to use more medication and suffer from increased infections:2
34% vs. 27%
p<0.00012
8% vs. 6%
p<0.00012
agent
63,405.4 vs. 53,397.1 units
p<0.00012
247.6 vs. 237.2 units
p<0.03142
20.7% vs. 14.1%
p<0.052
Missed dialysis sessions
CKD-associated Pruritus 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-associated Pruritus 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-associated Pruritus 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-associated Pruritus through shared team responsibility can ensure the best care for patients.
Management of CKD-associated Pruritus should be an essential part of treatment for all patients undergoing haemodialysis and suffering from CKD-associated Pruritus.7 Help your patients make informed choices about their treatment options for CKD-associated Pruritus.
- 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.
- 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.
- 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.
- 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.
- Gilman A, Sucha E, Kingsbury M, et al. Depression and mortality in a longitudinal study: 1952–2011. CMAJ. (2017);189(42):E1304–E1310.
- 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.
- 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.
