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Uraemic pruritus or chronic kidney disease-
associated pruritus(CKD-aP)
Dr Aoife Lowney
Consultant in Palliative Medicine and Renal Supportive Care
Oxford
• Prevalence is underestimated
• Impact is underestimated
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Symptom Burden in 893 Haemodialysis Patients
Lowney et. al JPSM 2015 epub ahead of print
Principle 1
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Not everyone with ESKD and itch has uraemicpruritus or (CKD-aP)
CKD-associated Pruritus
Examine the Skin thoroughly
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Itch Screen
Yosipovitch NEJM 2013; 368:1625-34
True Uraemic Pruritus or (CKD-aP) CKD-associated Pruritus
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Daily itching
Large Discontinuous but symmetric areas
Itch without a dermatosis or rash
Mathur et al Clin J Am Nephrol 2010;5:1410-9
The Butterfly Sign
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Worse at night
Mathur et al Clin J Am Nephrol 2010;5:1410-9
Back and Arms
Heat
Stress
Cold
Physical activity
Showering
Mistik S. J Eur Acad Dermatol Venereol. 2006;20:672-8
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Postulated Mechanisms
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90%10%
Yosipovitch NEJM 2013; 368:1625-34
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Scratching may lead to:
Impetigo
Prurigo
Chronic lichenified dermatitis/
eczema
Management
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Oral antihistamines and systemic steroids are
generally not effective
Combs Seminars in Nephrology 2015; 35:4, 383-391
Spoiler Alert
With the exception of the evidence for gabapentin, there remains considerable uncertainty for effective treatments
Simonsen et al AJKD 2017
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Grade A evidence ≥1 RCT
Gabapentin +/-Pregabalin
9 RCT
N=527
Longest treatment duration 12 weeks
Drowsiness dizziness and somnolence
Overall a statistically significant benefit in favour of intervention arm
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Mast Cell Stabalisers 5 studies n=237
Positive
Topical and oral Cromolyn sodium 2 positive studies (burning and flatulance)
Oral zinc sulfate more effective than placebo
Negative
Hydroxyzine negative study
Nicotinamide negative study
Phototherapy
2 studies significant benefit of broadband UV-B over UV-A
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HD Rx Modification
High flux HD
High permeability HD
Other Systemic Medications Positive
Trials
Montelukast n=80 one trial
Nalfuraline HCL oral n=339 one trial
Thalidomide n=29 one trial
Naltrexone 2x RCTs (The study with shorter duration and fewer participants
concluded that there was a significant effect of naltrexone compared to placebo)
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Other Systemic Medications Negative
Trials
Ondansetron 2 trials
Oral Primrose oil one trial
Cholestyramine ? Significant
Other Topical Medications Trials
Positive GLA (gamma linolineic acid) enriched cream
Capsaicin 2 crossover studies
Pramoxine Hcl 1% (topical anaesthetic caladryl)
Negative Dead sea mineral lotion
Tacrolimus
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Alternative Acupressure 2 positive trials
Homeopathy negative trial
Sertraline 50mg od
Shakiba et al 2012
Grade B Well Designed non-randomised studies
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Approach to Treatment
Combs Seminars in Nephrology 2015; 35:4, 383-391
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Approach to Treatment
Approach to Treatment
Combs Seminars in Nephrology 2015; 35:4, 383-391
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Approach to Treatment
Combs Seminars in Nephrology 2015; 35:4, 383-391
Evening Primrose Oil
Chen YC et al. Am J Kid Dis 2006; 48: 69-76
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supplementing the Gabba-Linolenic Acid (GLA) has an anti-inflammatory/ anti-itch effect
Approach to Treatment
Combs Seminars in Nephrology 2015; 35:4, 383-391
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ZincCapsaicin
Cromolyn sodium topical
Montelulkast
Treat high phosphate
Reactive Perforating Collagenosis
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Reactive Perforating Collagenosis
Acquired – occurs in adulthood, usually in patients with diabetes or chronic renal failure, especially those receiving dialysis
Reactive Perforating Collagenosis
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Abnormal collagen extruding through to the epidermis
Lesions appear in response to superficial trauma such as scratching and are aggravated by cold weather
Reactive Perforating Collagenosis
Isotretinoin
Allopurinol
Doxycycline
Phototherapy
Reactive Perforating Collagenosis
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