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Consequences oF
CKD-associated pRuritus
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Consequences of CKD-aP

Patients suffering from CKD-associated Pruritus (formerly referred to as uremic pruritus) may experience reduced sleep quality, social isolation and depression; the Worst Itch Intensity – Numerical Rating Scale (WI-NRS) and Self-Assessed Disease Severity (SADS) assessment scales can help you understand the burden of CKD-associated Pruritus on your patients’ lives.

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 patients’ perspectives.

CKD-associated Pruritus can influence patients’ moods; feelings of grumpiness and hopelessness often accompany the itch, leaving patients anxious to visit friends and relatives in fear of the next flare. 

Michel’s story

Michel tells his story of living with CKD‑associated Pruritus. From sleepless nights to preventing him from doing the things he enjoys, CKD‑associated Pruritus has had a huge impact on him and his family.

 

Raymond’s story

Raymond describes how living with CKD‑associated Pruritus has left him scarred, tired and alone. CKD‑associated Pruritus leaves Raymond with no choice but to itch and with no help in sight.

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

Sleep 1.6

Haemodialysis patients moderately affected by itching had a 1.4–1.6-fold higher adjusted odds of being awake at night, feeling sleepy during the day, or not having enough sleep, compared to patients not bothered by itchy skin.1

Sleep 2.5

Patients with severe (very much and extremely bothered by itching) CKDassociated 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

QoL 3.9

Haemodialysis patients with moderate pruritus had quality of life mental composite summary scores 3.9 points lower than HD patients with no pruritus.1*

*Not adjusted for sleep quality.

Haemodialysis patients with extremely bothered

Haemodialysis patients with extremely bothered by itching had quality of life mental composite summary scores 8.6 points lower than HD patients with not bothered by pruritus.1

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

Depression

The DOPPS study has reported an association 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

Patients suffering from moderate pruritus

Patients suffering from moderate pruritus were found to have 1.3 times higher odds of a depression diagnosis, compared to patients with no pruritus.1

Depression 2x

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

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 patients with CKD-associated Pruritus, the WI-NRS and SADS scale.

 

The Worst Itch Intensity – Numerical Rating Scale (WI-NRS) assesses 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:

WI-NRS-scale

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

DOWNLOAD PRURITUS INTENSITY PATIENT QUESTIONNAIRE HERE

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

alt

  • A:
  • • 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

 

alt

  • B:
  • • 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

 

alt

  • C:
  • • 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

DOWNLOAD SCALE HERE
The consequences of CKD-associated Pruritus lie beneath the surface

CKD-associated Pruritus is more likely to increase healthcare utilisation and severe CKD-associated Pruritus is associated with an increased risk of mortality, compared with patients without CKD-associated Pruritus.1,2,7,8 Look beneath the surface to discover the consequences of CKD-associated Pruritus.

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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.