The first steps in the management of CKD-aP are typically to ensure adequate dialysis, normalise calcium-phosphate balance, control parathyroid hormone (PTH) to accepted levels, correct any anaemia and use emollients (for xerosis).1
Dialysis optimisation may not be sufficient given the multifactorial pathogenesis. A multivariate analysis of 6,256 patients from DOPPS found no association between CKD-aP and phosphorus, calcium, calcium–phosphorus product, PTH, Kt/V, or hemodiafiltration.3
Despite antihistamines being widely used by patients, there is no evidence from randomised controlled trials to support their use.1,4
The perceived benefit of antihistamines is likely to be caused by sedation rather than an antipruritic effect, as many nonhistaminergic neurones are involved in the neural pathways that produce itch.5
Long term use of sedative antihistamines may predispose patients to dementia and should be avoided, except in palliative care.1
There is limited data to support the use of topical corticosteroids in CKD-aP. Moreover, corticosteroids are not intended to be used for prolonged periods.6
Corticosteroids are not directly antipruritic and it is believed they exert a beneficial effect on pruritus through their reduction in skin inflammation.6
A number of placebo-controlled trials using gabapentinoids have demonstrated a reduction in itch severity, however, the adverse effects associated with them may limit their use in CKD-aP.2
Adverse events observed with gabapentinoids include neurological events (for example dizziness and somnolence), weight gain, angio-oedema and increased suicide risk.2
Watch this video to hear about the treatment algorithm for CKD-aP.
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.
- 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.
- Verduzco H, Shirazian S. CKD-associated pruritus: new insights into diagnosis, pathogenesis, and management. Kidney Int Rep. (2020);5(9):1387–1402.
- 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.
- Mathur V, Lindberg J, Germain M, et al. A longitudinal study of uremic pruritus in hemodialysis patients. Clin J Am Soc Nephrol. (2010);5:1410–1419.
- Combs S, Teixeira J, Germain M. Pruritus in Kidney Disease. Semin Nephrol. (2015);35(4):383–391.
- Westby EP, Purdy KS, Tennankore KK. A review of the management of uraemic pruritus: current perspectives and future directions. Itch. (2020);5:e38. doi: 10.1097/itx.0000000000000038.