References
Pisoni RL, Wikström B, Elder SJ, et al. Pruritus in haemodialysis patients: International results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrol Dial Transplant. 2006;21:3495-3505.
Yamamoto Y, Hayashino Y, Yamazaki S, et al. Depressive symptoms predict the future risk of severe pruritus in haemodialysis patients: Japan Dialysis Outcomes and Practice Patterns Study. Br J Dermatol. 2009;161:384-389.
Aresi G, Rayner HC, Hassan L, et al. Reasons for Underreporting of Uremic Pruritus in People With Chronic Kidney Disease: A Qualitative Study. J Pain Symptom Manage. 2019;58:578-586.e2.
Reszke R, Szepietowski JC. End-Stage Renal Disease Chronic Itch and Its Management. Dermatol Clin. 2018;36:277-292.
Verduzco HA, Shirazian S. CKD-Associated Pruritus: New Insights Into Diagnosis, Pathogenesis, and Management. Kidney Int Rep. 2020;5:1387-1402.
Swarna SS, Aziz K, Zubair T, et al. Pruritus Associated With Chronic Kidney Disease: A Comprehensive Literature Review. Cureus. 2019;11:e5256-e5256.
Hu X, Sang Y, Yang M, et al. Prevalence of chronic kidney disease-associated pruritus among adult dialysis patients: A meta-analysis of cross-sectional studies. Medicine. 2018;97:e10633-e10633.
Mathur VS, Lindberg J, Germain M, et al. A longitudinal study of uremic pruritus in hemodialysis patients. Clin J Am Soc Nephrol. 2010;5:1410-1419.
Wojtowicz-Prus E, Kilis-Pstrusinska K, Reich A, et al. Disturbed skin barrier in children with chronic kidney disease. Pediatr Nephrol. 2015;30:333-338.
Pisoni RL, Gillespie BW, Dickinson DM, et al. The Dialysis Outcomes and Practice Patterns Study (DOPPS): design, data elements, and methodology. Am J Kidney Dis. 2004;44(5 Suppl 2):7-15.
Mettang T, Kremer AE. Uremic pruritus. Kidney Int. 2015;87:685-691.
Rehman IU, Chohan TA, Bukhsh A, et al. Impact of Pruritus on Sleep Quality of Hemodialysis Patients: A Systematic Review and Meta-Analysis. Medicine (Kaunas, Lithuania). 2019;55:699.
Combs SA, Teixeira JP, Germain MJ. Pruritus in Kidney Disease. Semin Nephrol. 2015;35:383-391.
Ramakrishnan K, Bond TC, Claxton A, et al. Clinical characteristics and outcomes of end-stage renal disease patients with self-reported pruritus symptoms. Int J Nephrol Renovasc Dis. 2013;7:1-12.
Sukul N, Speyer E, Tu C, et al. Pruritus and Patient-Reported Outcomes in Non-Dialysis CKD. Clin J Am Soc Nephrol. 2019;14:673-681.
Szepietowski JC, Reich A, Schwartz RA. Uraemic xerosis. Nephrol Dial Transplant. 2004;19:2709-2712.
Noh SH, Park K, Kim EJ. The Incidence of Pruritus and Biochemical Marker Associated with Pruritus in Hemodialysis Patients. Ann Dermatol. 2018;30:473-475.
Elman S, Hynan LS, Gabriel V, et al. The 5-D itch scale: a new measure of pruritus. Br J Dermatol. 2010;162:587-593.
Majeski CJ, Johnson JA, Davison SN, et al. Itch Severity Scale: a self-report instrument for the measurement of pruritus severity. Br J Dermatol. 2007;156:667-673.
Chen MM, Lasek RJ, Quinn LM, et al. Skindex, a quality-of-life measure for patients with skin disease: reliability, validity, and responsiveness. J Invest Dermatol. 1996;107:707-713.
Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI)--a simple practical measure for routine clinical use. Clin Exp Dermatol. 1994;19:210-216.
Hays RD, Kallich JD, Mapes DL, et al. Development of the kidney disease quality of life (KDQOL) instrument. Qual Life Res. 1994;3:329-338.
Rayner HC, Larkin M, Wang M, et al. International Comparisons of Prevalence, Awareness, and Treatment of Pruritus in People on Hemodialysis. Clin J Am Soc Nephrol. 2017;12:2000-2007.
Kuypers DR. Skin problems in chronic kidney disease. Nat Clin Pract Nephrol. 2009;5:157-170.
Millington GWM, Collins A, Lovell CR, et al. British Association of Dermatologists guidelines for the investigation and management of generalized pruritus in adults without an underlying dermatosis, 2018. Br J Dermatol. 2018;178:34-60.
Weisshaar E, Szepietowski JC, Dalgard FJ, et al. European S2k Guideline on Chronic Pruritus. Acta Derm Venereol. 2019;99:469-506.
Trachtenberg AJ, Collister D, Rigatto C. Recent advances in the treatment of uremic pruritus. Curr Opin Nephrol Hypertens. 2020;29:465-470.
Hiroshige K, Kabashima N, Takasugi M, et al. Optimal dialysis improves uremic pruritus. Am J Kidney Dis. 1995;25:413-419.
Liakopoulos V, Krishnan M, Stefanidis I, et al. Improvement in uremic symptoms after increasing daily dialysate volume in patients on chronic peritoneal dialysis with declining renal function. Int Urol Nephrol. 2004;36:437-443.
Masi CM, Cohen EP. Dialysis efficacy and itching in renal failure. Nephron. 1992;62:257-261.
Chou FF, Ho JC, Huang SC, et al. A study on pruritus after parathyroidectomy for secondary hyperparathyroidism. J Am Coll Surg. 2000;190:65-70.
Massry SG, Popovtzer MM, Coburn JW, et al. Intractable pruritus as a manifestation of secondary hyperparathyroidism in uremia. Disappearance of itching after subtotal parathyroidectomy. N Engl J Med. 1968;279:697-700.
Feily A, Dormanesh B, Ghorbani AR, et al. Efficacy of topical cromolyn sodium 4% on pruritus in uremic nephrogenic patients: a randomized double-blind study in 60 patients. Int J Clin Pharmacol Ther. 2012;50:510-513.
Young TA, Patel TS, Camacho F, et al. A pramoxine-based anti-itch lotion is more effective than a control lotion for the treatment of uremic pruritus in adult hemodialysis patients. J Dermatolog Treat. 2009;20:76-81.
Szepietowski JC, Morita A, Tsuji T. Ultraviolet B induces mast cell apoptosis: a hypothetical mechanism of ultraviolet B treatment for uraemic pruritus. Med Hypotheses. 2002;58:167-170.
Mettang T. Pruritus in Renal Disease. In: Carstens E, Akiyama T, eds. Itch: Mechanisms and Treatment. CRC Press/Taylor & Francis; 2014.
Lau T, Leung S, Lau W. Gabapentin for uremic pruritus in hemodialysis patients: a qualitative systematic review. Can J Kidney Health Dis. 2016;3:14.
Shavit L, Grenader T, Lifschitz M, et al. Use of pregabalin in the management of chronic uremic pruritus. J Pain Symptom Manage. 2013;45:776-781.
Rayner H, Baharani J, Smith S, et al. Uraemic pruritus: relief of itching by gabapentin and pregabalin. Nephron Clin Pract. 2012;122:75-79.
Amirkhanlou S, Rashedi A, Taherian J, et al. Comparison of Gabapentin and Ketotifen in Treatment of Uremic Pruritus in Hemodialysis Patients. Pak J Med Sci. 2016;32:22-26.
Dawn AG, Yosipovitch G. Butorphanol for treatment of intractable pruritus. J Am Acad Dermatol. 2006;54:527-531.
Mathur VS, Kumar J, Crawford PW, et al. A Multicenter, Randomized, Double-Blind, Placebo-Controlled Trial of Nalbuphine ER Tablets for Uremic Pruritus. Am J Nephrol. 2017;46:450-458.
Fishbane S, Jamal A, Munera C, et al. A Phase 3 Trial of Difelikefalin in Hemodialysis Patients with Pruritus. N Engl J Med. 2020;382:222-232.
Carstens E, Follansbee T, Iodi Carstens M. The Challenge of Basic Itch Research. Acta dermato-venereologica. 2020;100:adv00023.
Patel TS, Freedman BI, Yosipovitch G. An update on pruritus associated with CKD. Am J Kidney Dis. 2007;50:11-20.
Shirazian S, Aina O, Park Y, et al. Chronic kidney disease-associated pruritus: impact on quality of life and current management challenges. Int J Nephrol Renovasc Dis. 2017;10:11-26.
Wang H, Yosipovitch G. New insights into the pathophysiology and treatment of chronic itch in patients with end-stage renal disease, chronic liver disease, and lymphoma. Int J Dermatol. 2010;49:1-11.
Kimmel M, Alscher DM, Dunst R, et al. The role of micro-inflammation in the pathogenesis of uraemic pruritus in haemodialysis patients. Nephrol Dial Transplant. 2006;21:749-755.
Hashimoto T, Yosipovitch G. Itching as a systemic disease. J Allergy Clin Immunol. 2019;144:375-380.
Phan NQ, Lotts T, Antal A, et al. Systemic kappa opioid receptor agonists in the treatment of chronic pruritus: a literature review. Acta Derm Venereol. 2012;92:555-560.
Susel J, Batycka-Baran A, Reich A, et al. Uraemic pruritus markedly affects the quality of life and depressive symptoms in haemodialysis patients with end-stage renal disease. Acta Derm Venereol. 2014;94:276-281.
Szepietowski JC, Balaskas E, Taube KM, et al. Quality of life in patients with uraemic xerosis and pruritus. Acta Derm Venereol. 2011;91:313-317.
Weiss M, Mettang T, Tschulena U, et al. Prevalence of chronic itch and associated factors in haemodialysis patients: a representative cross-sectional study. Acta Derm Venereol. 2015;95:816-821.
Albert-Vartanian A, Boyd MR, Hall AL, et al. Will peripherally restricted kappa-opioid receptor agonists (pKORAs) relieve pain with less opioid adverse effects and abuse potential? J Clin Pharm Ther. 2016;41:371-382.

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Faculty

James Burton DM, FRCP

Professor of Renal Medicine
Honorary Consultant Nephrologist
Department of Cardiovascular Sciences
University of Leicester
United Kingdom

Disclosures

Disclosure: James Burton, DM, FRCP, has disclosed the following relevant financial relationships:
Served as an advisor or consultant for: Pharmacosmos; Vifor Pharma
Served as a speaker or a member of a speakers bureau for: Amgen; AstraZeneca; Bristol Myers Squibb; NAPP; Pfizer
Received grants for clinical research from: National Institute of Health Research; Yakult

Editors

Joy P. Marko, MS, APN-C, CCMEP

Senior Medical Education Director, Medscape, LLC

Disclosures

Disclosure: Joy P. Marko, MS, APN-C, CCMEP, has disclosed no relevant financial relationships.

Ruwaida Vakil, MSc

ProMed Write LLC
Professional Medical Writing and Content Development Services

Disclosures

Disclosure: Ruwaida Vakil, MSc, has disclosed the following relevant financial relationships:
Owns stock, stock options, or bonds from: Pfizer

Content Reviewer

Esther Nyarko, PharmD

Associate Director, Accreditation and Compliance, Medscape LLC

Disclosures

Disclosure: Esther Nyarko, PharmD, has disclosed no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has disclosed the following relevant financial relationships: Roche Diagnostics inc

CPD

Patient Case Challenges in CKD-aP

Authors: James Burton DM, FRCP
CPD Released: 5/17/2021
THIS ACTIVITY HAS EXPIRED FOR CREDIT
Valid for credit through: 5/17/2022

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Target Audience and Goal Statement

This educational activity is intended for an international audience of non-US nephrologists and dermatologists.

The goal of this activity is to help clinician diagnose and understand severity assessment for CKD-aP while looking forward to implementation of novel therapies for CKD-aP into clinical practice.

Upon completion of this activity, participants will:

Have increased knowledge regarding
- The Diagnosis and severity assessment for CKD-aP
- Optimizing outcomes for CKD-aP
- Introducing novel therapies for CKD-aP into clinical practice

Disclosures

Faculty

James Burton DM, FRCP

Professor of Renal Medicine
Honorary Consultant Nephrologist
Department of Cardiovascular Sciences
University of Leicester
United Kingdom

Disclosures

Disclosure: James Burton, DM, FRCP, has disclosed the following relevant financial relationships:
Served as an advisor or consultant for: Pharmacosmos; Vifor Pharma
Served as a speaker or a member of a speakers bureau for: Amgen; AstraZeneca; Bristol Myers Squibb; NAPP; Pfizer
Received grants for clinical research from: National Institute of Health Research; Yakult

Editors

Joy P. Marko, MS, APN-C, CCMEP

Senior Medical Education Director, Medscape, LLC

Disclosures

Disclosure: Joy P. Marko, MS, APN-C, CCMEP, has disclosed no relevant financial relationships.

Ruwaida Vakil, MSc

ProMed Write LLC
Professional Medical Writing and Content Development Services

Disclosures

Disclosure: Ruwaida Vakil, MSc, has disclosed the following relevant financial relationships:
Owns stock, stock options, or bonds from: Pfizer

Content Reviewer

Esther Nyarko, PharmD

Associate Director, Accreditation and Compliance, Medscape LLC

Disclosures

Disclosure: Esther Nyarko, PharmD, has disclosed no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has disclosed the following relevant financial relationships: Roche Diagnostics inc

Accreditation Statements

For Physicians

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The following cases are modeled on the interactive grand rounds approach. The questions within the activity are designed to test your current knowledge. After each question, you will be able to see whether you answered correctly and read evidence-based information that supports the most appropriate answer choice. The questions are designed to challenge you; you will not be penalized for answering the questions incorrectly. At the end of the activity, there will be a short post-test assessment based on the material presented.

Case 1

Prevalence of CKD-aP, Diagnosis of CKD-aP and Assessing Severity, the Impact of Uremic Pruritus, Management Strategies, Treatment Goals

Pablo is a 50-year-old man with end-stage kidney disease. He has been on hemodialysis for about eight years. Over the past four weeks, he has been scratching his skin constantly; he says he cannot sleep at night because of itching, and it is disturbing his wife's sleep. Pablo says the itching is so bad that he can barely sit through dialysis.

Table 1. Pablo’s Initial Work-up

	Results
Past medical history	· Diabetes for the past 10 years · Ischemic heart disease for 5 years
Medications	· Linagliptin 5 mg, once a day · Aspirin 75 mg, once a day · Atorvastatin 20 mg, once a day · Amlodipine 10 mg, once a day · Darbepoetin alfa 40 μg, once a week (for anemia) · Iron sucrose 200 mg, every two weeks
Allergies	· No known drug allergies
Social history	· Smokes 2 packs a day with a 30 pack-year history · Drinks 14 units of alcohol per week · Lives with wife, aged 47 · Has 3 children · Worked for 30 years as a welder
Family history	· Mother deceased (age 79, heart attack) · Father deceased (age 64, prostate cancer) · 1 brother (age 40, hypertension) · 1 sister (age 45, hyperlipidemia)
Physical exam: Vitals	· Height = 180.3 cm (71 inches) · Weight = 91.4 kg (201.5 pounds) · Body mass index (BMI) = 28.1 · Blood Pressure (BP) = 130/82 mm Hg · Heart rate = 85 bpm at rest
Most recent blood results	· Hemoglobin 112 g/L (130–180) · Serum corrected calcium 2.3 mmol/L (2.20–2.60) · Serum phosphate 1.85 mmol/L (0.8–1.4)

Page 1 of 12

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The educational activity presented above may involve simulated case-based scenarios. The patients depicted in these scenarios are fictitious and no association with any actual patient is intended or should be inferred.

The material presented here does not necessarily reflect the views of WebMD Global, LLC or companies that support educational programming on medscape.org. A qualified healthcare professional should be consulted before using any therapeutic product discussed. Readers should verify all information and data before treating patients or employing any therapies described in this educational activity.

References

Faculty and Disclosures

Faculty

James Burton DM, FRCP

Editors

Joy P. Marko, MS, APN-C, CCMEP

Ruwaida Vakil, MSc

Content Reviewer

Esther Nyarko, PharmD

Peer Reviewer

CPD

Patient Case Challenges in CKD-aP

Target Audience and Goal Statement

Disclosures

Faculty

James Burton DM, FRCP

Editors

Joy P. Marko, MS, APN-C, CCMEP

Ruwaida Vakil, MSc

Content Reviewer

Esther Nyarko, PharmD

Peer Reviewer

Accreditation Statements

For Physicians

Instructions for Participation and Credit

Patient Case Challenges in CKD-aP

Case 1

Prevalence of CKD-aP, Diagnosis of CKD-aP and Assessing Severity, the Impact of Uremic Pruritus, Management Strategies, Treatment Goals