What are the treatment options for pruritis (itching sensation) in a patient with chronic kidney disease (CKD)?

Treatment of Pruritus in Chronic Kidney Disease

Start with gabapentin 100-300 mg after each dialysis session (three times weekly) as first-line systemic therapy for CKD-associated pruritus, combined with regular emollients and optimization of dialysis parameters. 1, 2, 3

Initial Assessment and Baseline Management

Before initiating specific antipruritic therapy, address these foundational elements:

• Ensure adequate dialysis with a target Kt/V of approximately 1.6, as pruritus is significantly more common in underdialyzed patients 1, 2, 3
• Normalize calcium-phosphate balance and control parathyroid hormone levels to accepted ranges, as secondary and tertiary hyperparathyroidism frequently accompany end-stage renal disease and contribute to pruritus 1, 2, 3
• Correct anemia with erythropoietin if present 2, 3
• Apply emollients regularly to all affected areas, as xerosis (dry skin) is the most common cutaneous finding in dialysis patients and lowers the threshold for itch 1, 2, 3, 4

First-Line Pharmacologic Treatment

Gabapentin remains the most effective medication based on the strongest evidence:

• Dose: 100-300 mg administered after each dialysis session (three times weekly) - note these doses are substantially lower than non-ESRD populations due to reduced renal clearance 1, 2, 3, 5
• A multicentre, double-blind, placebo-controlled trial demonstrated good response rates with visual analogue ratings falling in excess of 50% compared to placebo 1
• Gabapentin has also been shown to improve depression and sleep disturbances associated with pruritus in dialysis patients 1
• Common side effects include mild drowsiness 3

Topical Therapy Options

For localized pruritus or as adjunctive therapy:

• Capsaicin 0.025% cream applied four times daily is highly effective, with 14 out of 17 patients in randomized trials reporting marked relief and 5 achieving complete remission 1, 2, 3, 6
• Capsaicin works by depleting neuropeptides including substance P in peripheral sensory neurons 2
• The antipruritic effect can persist up to 8 weeks after cessation of treatment 1
• Topical calcipotriol can be considered for localized areas 1, 3

Second-Line Treatment

If gabapentin provides insufficient relief after 2-4 weeks:

• Broad-band UVB (BB-UVB) phototherapy is effective for many patients with uremic pruritus and has strong supporting evidence 2, 3, 5
• Topical doxepin may be considered for severe cases, but treatment must be strictly limited to 8 days, 10% of body surface area, and maximum 12 g daily 3

Critical Pitfalls to Avoid

Do not use cetirizine - it has been specifically shown to be ineffective for uremic pruritus despite efficacy in other pruritic conditions 1, 2, 3, 5, 7

Avoid long-term sedating antihistamines (diphenhydramine, hydroxyzine) except in palliative care settings, as they may predispose to dementia 1, 3, 5, 8

Do not use calamine lotion - there is no literature supporting its use for uremic pruritus 2, 3

Avoid crotamiton cream - it has been shown ineffective compared to vehicle control 2, 3

Alternative Agents with Limited Evidence

These may be considered when first-line options fail:

• Ketotifen may be as effective as gabapentin but has less overall supporting evidence 1, 3
• Kappa-opioid agonists (nalfurafine) reduce itch but show a much more modest effect compared to gabapentin 7
• Ondansetron had little or no effect on itch scores and should not be used 1, 7

Definitive Treatment

Renal transplantation is the only definitive cure for uremic pruritus but is not always feasible 1, 3, 5

Clinical Presentation Patterns

Understanding the typical presentation helps confirm the diagnosis:

• Approximately 50% of patients experience generalized pruritus, while others have localized symptoms affecting the back, face, or arteriovenous fistula arm 1, 9
• Pruritus commonly worsens during summer or at night 1
• Some patients experience itch during or soon after dialysis treatment, usually beginning within 6 months of dialysis onset 1
• The presence of bilaterally symmetrical and non-dermatomally distributed itching is characteristic of CKD-associated pruritus 9