From the Guidelines
Renal transplantation is the only definite treatment for uraemic pruritus, but for patients experiencing itchiness after kidney transplantation, I recommend considering gabapentin as a treatment option, starting at 100mg three times daily, as it has been shown to be effective in treating neuropathic itching 1. When managing itchiness after kidney transplantation, it's essential to consider the potential causes, including immunosuppressive medications, particularly tacrolimus and cyclosporine, which are calcineurin inhibitors.
- For mild itching, over-the-counter antihistamines like diphenhydramine 25-50mg every 6 hours as needed can be used, but sedative antihistamines long term may predispose to dementia and should be avoided, except in palliative care 1.
- Topical treatments such as moisturizers containing colloidal oatmeal or 1% hydrocortisone cream can provide localized relief when applied to itchy areas 2-3 times daily.
- For moderate to severe itching that doesn't respond to these measures, consulting the transplant physician is crucial, as they may consider adjusting the immunosuppressant dosage or switching to an alternative medication.
- It's also important to note that BB-UVB is an effective treatment for many patients with uraemic pruritus, and patients with uraemic pruritus should consider auricular acupressure or aromatherapy 1. The itching occurs because calcineurin inhibitors can trigger histamine release and neurogenic inflammation.
- It's crucial to avoid scratching as this can damage skin and lead to infections, which is particularly dangerous while immunosuppressed.
- Staying well-hydrated and using mild, fragrance-free soaps can help prevent further skin irritation. Always inform the transplant team about persistent itching as it could also indicate other issues like elevated kidney function tests or medication interactions.
From the Research
Itchiness Following Kidney Transplant
Itchiness is a common problem after kidney transplantation, with various studies indicating its prevalence and potential causes.
- The study 2 found that itch was present in 38.6% of patients during hemodialysis, and in 73.7% of cases, the itch ceased completely after successful transplantation.
- However, the study also noted that 21.3% of renal transplant recipients reported itch, with 52.4% of cases appearing after transplantation.
- The most frequently affected areas were extremities (50%) and the back (50%), with hot water being the most commonly reported alleviating factor.
Medications Associated with Itchiness
Certain medications have been linked to itchiness in kidney transplant patients.
- The study 3 suggested that tacrolimus, an immunosuppressive medication, may be associated with an increased occurrence of IgE-mediated sensitization and allergic disease.
- The study 4 reported a case of pruritus in a kidney transplant patient that was eventually diagnosed as scabies, highlighting the importance of considering common causes of pruritus unrelated to transplantation.
- The review 5 discussed the use of immunosuppressive drugs in renal transplant recipients, including calcineurin inhibitors, corticosteroids, and antiproliferative drugs, which can carry risks of certain side effects, including itchiness.
Treatment and Management
Treatment of itchiness in kidney transplant patients often involves a combination of topical and systemic therapies.
- The review 6 discussed the current state of knowledge on pruritus in renal transplant recipients, including the pathogenesis and treatment options.
- The study 2 noted that sweat was responsible for itch aggravation in 35.9% of cases, highlighting the importance of managing sweat and other exacerbating factors.
- The study 4 reported that treatment with oral ivermectin and topical permethrin resulted in complete resolution of symptoms within 1 week in a patient with scabies-induced pruritus.