What is the treatment for pruritus (itching) in patients with Chronic Kidney Disease (CKD)?

Treatment for Pruritus in Chronic Kidney Disease (CKD)

The management of CKD-associated pruritus requires a stepwise approach starting with optimization of dialysis adequacy, normalization of calcium-phosphate balance, control of parathyroid hormone levels, correction of anemia with erythropoietin, and use of emollients before implementing other treatment strategies. 1

First-Line Treatments

• Emollients should be provided as supportive care to address xerosis (dry skin), which is the most common cutaneous sign in dialysis patients and may lower the threshold for itch 1
• Ensure adequate dialysis - pruritus is more common in underdialysed patients and symptoms may improve by increasing dialysis dose (target Kt/V of around 1.6) 1
• Normalize calcium-phosphate balance and control parathyroid hormone to accepted levels, as secondary and tertiary hyperparathyroidism often accompany ESRD and may contribute to pruritus 1
• Correct anemia with erythropoietin if present 1

Second-Line Treatments

• Topical capsaicin 0.025% cream applied four times daily has shown significant efficacy in randomized trials, with 14 out of 17 patients reporting marked relief and 5 achieving complete remission of pruritus 1, 2
• Gabapentin (100-300 mg after dialysis, three times per week) is effective for uremic pruritus and should be considered when first-line measures are insufficient 3, 4
• Broad-band UVB (BB-UVB) phototherapy is an effective treatment for many patients with uremic pruritus with strong evidence supporting its use 1

Third-Line Treatments

• Topical doxepin can be considered for severe cases, but treatment should be limited to 8 days, 10% of body surface area, and 12 g daily 1
• Non-sedative antihistamines such as fexofenadine 180 mg or loratadine 10 mg, or mildly sedative agents such as cetirizine 10 mg may be tried, though evidence for their efficacy specifically in uremic pruritus is limited 1
• Hydroxyzine 25 mg three to four times daily may be used for short-term management of pruritus, particularly in palliative settings 1, 5

Important Considerations and Pitfalls

• Long-term use of sedative antihistamines may predispose to dementia and should be avoided except in palliative care settings 1
• Cetirizine is not effective specifically for uremic pruritus despite its use in other pruritic conditions 1
• Renal transplantation is the only definitive treatment for uremic pruritus but is not always feasible 1
• CKD-associated pruritus is often underdiagnosed and undertreated despite affecting up to 60% of dialysis patients and significantly impacting quality of life 4, 6
• Xerodermia (dry skin) is strongly associated with pruritus in CKD patients - 109 out of 187 patients with xerodermia experienced pruritus in one study 7

Monitoring and Follow-up

• Regularly assess pruritus intensity and impact on quality of life 4, 8
• Consider that pruritus in CKD patients can be generalized (in approximately 50% of cases) or localized (commonly affecting the back, face, or arteriovenous fistula arm) 1, 8
• The intensity can range from mild intermittent irritation to intractable itch that severely disrupts sleep and quality of life 1
• Pruritus may worsen during summer or at night, and some patients experience itch during or soon after dialysis treatment 1

By following this algorithmic approach to managing CKD-associated pruritus, clinicians can significantly improve patient comfort and quality of life while addressing this common but often overlooked complication of kidney disease.