CKD Associated Pruritus

Overview                   

Pruritis is an unpleasant sensation of the skin or mucous membranes that promotes the desire to scratch or rub. It is common in patients with kidney and liver disease/cholestasis and can be caused by multiple factors and can be extremely distressing leading to poor sleep, anxiety, and depression.

  • Not all itch in advanced CKD is because of CKD - consider other causes first
  • Pruritis can be divided into 4 categories:
    1. Proprioceptive pruritis – originates in the skin and can be triggered by several chemical mediators (e.g. histamine, cytokines, opioids, and neuropeptides,dermatological disorders, inflammation, infestation, contact dermatitis, xerosis)
    2. Neuropathic pruritis – damage along the afferent pathways causing itch, such as post-herpetic pruritus
    3. Neurogenic pruritis –  such as uremic or cholestatic itch, centrally induced and unresponsive to anti-histamines
    4. Psychogenic pruritis – associated with psychiatric disorders and is the least common category
  • CKD associated pruritus is a common and often severe symptom for patients with advanced stage kidney disease 
  • Cirrhosis/Cholestasis: the intensity does not correlate with the severity of underlying liver disease (e.g. it has diurnal variation, worse itch in the late evening)
  • Opioid-induced itch: likely centrally mediated
  • Solid tumors (e.g. paraneoplastic pruritis may involve an immunologic reaction to tumor specific antigens)
  • Hematologic disorders (e.g. lymphoma, polycythemia vera)
  • Metabolic Disturbances (e.g. iron deficiency)
  • Drug Hypersensitivities
  • Dry skin conditions

General Principles

  • Non-pharmacological management should be attempted in all patients
  • Provide patients with the Itchiness Patient Handout
  • Good skin care and moisturizers are considered first line treatment

Soak & Seal

  • Baths are better than showers (daily in lukewarm water for at least 15 min)
  • Avoid harsh soaps, body washes, bubble baths etc. Try mild, unscented soap or gentle cleansers (e.g. CeraVe, Cetaphil), and only in limited places such as the axilla and groin areas.
  • Post bath: pat dry and moisturize skin within two minutes of getting out. Skin will still be damp. Ideally, use hypoallergenic moisturizers with ceramides (e.g. CeraVe) that are free from fragrance and additives
  • Do not use the moisturizers on areas of broken skin
  • Topical baby oil up to three times a week has shown positive effects on itching, sleep, and overall quality of life

Other personal care tips: 

  • Try not to scratch
    • Keep finger and toe nails short and filed
    • Use of cotton gloves at night for those individuals with the strong urge to scratch
    • Encourage massaging and gentle pressure rather than scratching
  • Keep skin cool by wearing light, loose, cotton clothing
  • Use natural fiber bedding
  • Maintain a humid home environment, especially in the winter; try using a cool humidifier in bedrooms and in common areas
  • Limit/avoid vasodilators such as coffee, alcohol, spices, and hot water

Ultraviolet B light therapy (phototherapy)

  • Not much is known about the long-term effects of UVB, but a trial of three times a week for 3 weeks may provide some relief for a period of time. Requires referral to Dermatology

Acupuncture

  • Although there is a lack of good evidence about its efficacy, patients may wish to consider this as an alternative or complementary treatment option

General Principles

  • The goal of therapy is to balance symptom control with careful protection of physical function and cognition
  • Treat the patient's daily pruritus if it is impairing their sleep or quality of life
    • If pruritus persists and is localized, consider topical pharmacological treatment
    • If pruritus persists despite topical therapies OR if pruritus is generalized, systemic treatment may be beneficial
    • Antihistamines are not recommended in the treatment of CKD Associated Pruritus 

Pramoxine

  • Gold Bond Medicated Anti-Itch products (OTC) – contain pramoxine, dimethicone, menthol
  • Pramox HC (hydrocortisone 1%/pramoxine 1%) - apply two times a day for 4 weeks
  • Caution for use around eyes

Capsaicin 0.025% or 0.075% Ointment

  • Zostrix 0.025% and Zostrix Hp 0.075%
  • Can be applied 2-4 times a day to affected areas
  • It may initially cause burning to the area
  • Wear gloves while applying or wash hands thoroughly afterwards 

Menthol, Camphor and Phenol are separate products that can be added to most creams, typically in the range of 0.3-1.0%

  • All three may be added together, commonly with a 0.3% concentration for each
  • Must be compounded by pharmacy

Gamma-Linolenic acid (GLA) 2.2% cream

  • Apply cream twice daily to identified dry skin
  • May not be easily accessible in Alberta

Gabapentin First-line Agent

Pregabalin First-line Agent

  • It should be taken 1-2 hours before bedtime due to delay of onset
  • Do not discontinue abruptly. When discontinued, their doses should be tapered over 1-2 weeks 

Sertraline Fourth-line Agent

Initial 50 mg daily PO; titrate to 75–100 mg daily PO 

One:carepath Itchiness Patient Handout

One:carepath Pain Patient Handout

One:carepath Sleep Problems Patient Handout

One:carepath Anxiety & Depression Patient Handout