How to manage itching in patients with Chronic Kidney Disease (CKD) stage 5 and hypertension?

Management of Itching in CKD Stage 5 Patients with Hypertension

Start with gabapentin 100-300 mg after each dialysis session (three times weekly) as first-line pharmacologic therapy for uremic pruritus in CKD stage 5 patients, while simultaneously optimizing dialysis adequacy and managing hypertension with volume control and ACE inhibitors or ARBs. 1, 2

Hypertension Management Framework

Volume control is the cornerstone of hypertension management in CKD stage 5, as volume overload is the major contributor to hypertension in this population and directly impacts cardiovascular outcomes 1. Target predialysis blood pressure should be <140/90 mm Hg, though evidence for specific targets in stage 5 CKD remains limited 1.

Volume Optimization Strategy

• Restrict dietary sodium and water intake as the primary intervention 1
• Achieve dry weight through adequate dialysis with target Kt/V of approximately 1.6 1
• Use loop diuretics if residual kidney function exists and signs of volume overload are present 1
• Monitor blood pressure, drain volume, and residual kidney function monthly 1

Antihypertensive Medication Selection

• First-line: ACE inhibitors or ARBs reduce left ventricular hypertrophy and are associated with decreased mortality in observational studies 1
• Second-line: Beta-blockers if prior myocardial infarction or established coronary artery disease exists 1
• Additional agents: Calcium channel blockers are associated with decreased cardiovascular mortality and can be added for inadequate control 1
• Multiple medications are typically required; add a second or third drug from different classes if blood pressure remains uncontrolled 1

Uremic Pruritus Management Algorithm

Step 1: Optimize Dialysis and Metabolic Parameters

Before initiating specific antipruritic therapy, ensure adequate dialysis and correct metabolic abnormalities 1:

• Verify dialysis adequacy with Kt/V around 1.6 1
• Normalize calcium-phosphate balance 1
• Control parathyroid hormone to accepted levels 1
• Correct anemia with erythropoietin 1
• Apply emollients liberally for xerosis (dry skin), which is present in most dialysis patients 1

Step 2: First-Line Pharmacologic Therapy

Gabapentin is the most effective treatment with the strongest evidence base 1, 2, 3:

• Dose: 100-300 mg after each dialysis session (three times weekly) 1
• Alternative: 400 mg twice weekly after hemodialysis sessions 1
• Note these doses are substantially lower than non-ESRD populations due to reduced clearance 1
• Expected response: Significant improvement in visual analogue scale scores with mild drowsiness as the main side effect 1
• Evidence quality: Multiple RCTs demonstrate efficacy; high certainty evidence from Cochrane review showing 4.95 cm reduction in 10 cm VAS compared to placebo 2

Step 3: Alternative or Adjunctive Therapies

If gabapentin is ineffective or not tolerated 1, 2:

Topical capsaicin 0.025% cream:

• Apply four times daily to affected areas 1, 4
• Marked relief reported in 14 of 17 patients in RCT, with 5 achieving complete remission 1
• Prolonged antipruritic effect up to 8 weeks after cessation 1
• Wash hands thoroughly after application unless treating hands 4

Kappa-opioid agonists (nalfurafine):

• Reduces itch with high certainty evidence (1.05 cm reduction in VAS) 2
• Effect more modest compared to gabapentinoids 2

Other options with limited evidence:

• Pregabalin (alternative gabapentinoid) 2
• Montelukast, turmeric, zinc sulfate (small studies showing benefit) 2

Step 4: Therapies to AVOID

Do not use cetirizine - specifically ineffective for uremic pruritus despite efficacy in other conditions 1, 5

Avoid long-term sedating antihistamines (diphenhydramine, hydroxyzine) except in palliative care, as they may predispose to dementia 1, 5

Ondansetron has little or no effect on uremic pruritus (high certainty evidence) 2

Critical Pitfalls to Avoid

• Do not assume antihistamines work for uremic pruritus - they lack substantial evidence and cetirizine is specifically ineffective 1, 5, 2
• Do not use standard gabapentin dosing - CKD stage 5 patients require dramatically reduced doses (100-300 mg three times weekly vs. daily dosing in non-CKD patients) 1
• Do not neglect volume status - inadequate volume control undermines both hypertension and potentially pruritus management 1
• Do not overlook hyperparathyroidism - secondary and tertiary hyperparathyroidism often accompany ESRD and may contribute to pruritus 1

Monitoring Parameters

• Assess blood pressure, volume status, and drain volume monthly 1
• Evaluate pruritus severity at each dialysis session using standardized scales (10 cm Visual Analogue Scale preferred) 2, 6
• Monitor for gabapentin side effects, particularly drowsiness 1
• Reassess dry weight regularly, especially in initial weeks of dialysis 1