What is the workup for vertigo and chronic pruritis in an 81-year-old female with Chronic Kidney Disease (CKD)?

Workup for Vertigo and Chronic Pruritus in an 81-Year-Old Female with CKD

For an 81-year-old female with CKD experiencing vertigo and chronic pruritus, the workup should focus on identifying treatable causes specific to CKD, with uremic pruritus requiring evaluation of dialysis adequacy, calcium-phosphorus balance, and parathyroid hormone levels, while vertigo assessment should include vestibular testing and cardiovascular evaluation.

Workup for Chronic Pruritus in CKD

Initial Assessment

• Confirm diagnosis of uremic pruritus by evaluating:
  • Pattern: Typically bilateral, symmetrical, non-dermatomal distribution (commonly affecting back, limbs, chest, head) 1
  • Timing: Worsening during dialysis or at night
  • Presence of secondary skin lesions (excoriations, crusts, lichenifications)
  • Xerosis (dry skin), which is extremely common in CKD patients 2

Laboratory Evaluation

1. Renal Function Assessment:

   • Urea and creatinine levels
   • eGFR calculation to determine CKD stage

2. Mineral Metabolism Parameters:

   • Calcium and phosphorus levels (calcium-phosphate imbalance contributes to pruritus)
   • Parathyroid hormone (PTH) levels (secondary hyperparathyroidism is associated with uremic pruritus) 2

3. Inflammatory Markers:

   • C-reactive protein (CRP) (elevated levels correlate with pruritus severity) 2

4. Hematological Assessment:

   • Complete blood count (anemia may contribute to pruritus symptoms) 2

5. Rule Out Other Causes:

   • Liver function tests (to exclude cholestatic pruritus)
   • Thyroid function tests (hypothyroidism can cause pruritus)
   • Skin biopsy if atypical presentation or suspected dermatological condition

Dialysis-Related Assessment

• Evaluate dialysis adequacy (target Kt/V ~1.6) 2
• Consider dialysis modality (peritoneal dialysis generally results in lower pruritus severity) 2

Workup for Vertigo in CKD

Initial Assessment

• Characterize vertigo:
  • Onset (sudden vs. gradual)
  • Duration (seconds, minutes, hours, days)
  • Triggers (positional changes, specific movements)
  • Associated symptoms (hearing loss, tinnitus, nausea, vomiting)

Neurological Evaluation

1. Vestibular Testing:

   • Dix-Hallpike maneuver (for benign paroxysmal positional vertigo)
   • Head impulse test
   • Nystagmus evaluation

2. Neuroimaging:

   • MRI brain (with special attention to posterior fossa structures)
   • Consider advanced MRI techniques as CKD patients may have microstructural changes affecting brain function 3

Cardiovascular Assessment

• Orthostatic blood pressure measurements (lying, sitting, standing)
• ECG to assess for arrhythmias (particularly atrial fibrillation, which is common in CKD) 3
• Consider Holter monitoring if intermittent symptoms 3

Medication Review

• Complete medication review to identify potential causes:
  • Antihypertensives (causing orthostatic hypotension)
  • Loop diuretics
  • Antibiotics (aminoglycosides)
  • Sedatives
  • Adjust medication dosing based on current eGFR 3

Management Recommendations

For Chronic Pruritus

Non-Pharmacological Approaches

• Regular use of emollients for xerosis 2
• Avoid hot water bathing and harsh soaps
• Maintain cool, humid environment
• Consider dietary modifications (limit processed foods with high potassium) 3

Pharmacological Management (Stepwise Approach)

1. First-line:

   • Topical capsaicin 0.025% cream applied four times daily 2

2. Second-line:

   • Gabapentin 100-300 mg after each dialysis session (dose adjusted for CKD) 2
   • Pregabalin with doses adjusted according to creatinine clearance 2

3. Third-line:

   • UVB phototherapy for refractory cases 2
   • Activated charcoal oral therapy 2

4. Avoid:

   • Sedating antihistamines, especially in elderly patients (may predispose to dementia) 2
   • NSAIDs for symptom management (contraindicated in CKD) 3

For Vertigo

Management Based on Etiology

• For BPPV: Canalith repositioning procedures (Epley maneuver)
• For orthostatic hypotension: Medication adjustment, compression stockings, increased fluid intake (if appropriate for CKD status)
• For cardiovascular causes: Management of atrial fibrillation or other arrhythmias according to CKD-specific guidelines 3

Medication Considerations

• If pharmacotherapy needed, use with caution:
  • Avoid medications with significant renal clearance
  • Consider NOACs over vitamin K antagonists if anticoagulation needed for atrial fibrillation (with appropriate dose adjustment for GFR) 3

Special Considerations for Elderly CKD Patients

• Start medications at lower doses with slower titration 2
• Monitor for drug interactions due to polypharmacy
• Assess fall risk, especially with vertigo symptoms
• Consider quality of life impact of symptoms when determining treatment aggressiveness
• Evaluate for cognitive impairment that may affect symptom reporting and medication adherence

Follow-up Recommendations

• Regular reassessment of symptoms using validated tools
• Periodic laboratory monitoring of renal function and electrolytes
• Adjustment of medication dosing with changes in GFR
• Consider nephrology consultation for optimization of CKD management