Pruritus in Chronic Kidney Disease

Nupur N. Uppal; Antonio Corona; Steven Fishbane


Curr Opin Nephrol Hypertens. 2022;31(5):435-441. 

In This Article

Clinical Evaluation

Because of the frequency and occasional severity of CKD-aP it's important that providers specifically ask all patients about whether they are experiencing itching. When present then a focused history and examination should be conducted. Questions should be directed at better understanding the extent of the problem (Table 1, Figure 1). When itching is moderate to severe then it is helpful to ask about how long it's been present, whether on dialysis or at other times as well, parts of the body affected, previous treatments and impact on the patient's life. On this latter point, important focus areas are on impairment of social functioning and the extent to which sleep has been affected.

Figure 1.

Approach to patients with chronic kidney disease-associated pruritus. The initial clinical evaluation should include a directed history and examination. Treatment can follow from the clinical findings. In cases with moderate to severe itching, difelikefalin can be started with the initial treatment duration based on the presenting findings. An initial 3-month course would be appropriate for most patients.

Physical exam should include a focus on the skin in areas where itch is greatest. Throughout the year, but especially in winter in temperate climates, dry skin may be a problem. The skin will appear scaly with redness over areas of scratching. The most common areas for dry skin are the hands and feet, the lower legs and the forearms. Examination of the skin should also focus on areas where rash suggests other causes of itching. Detecting skin lesions such as psoriasis or eczema can direct treatment or lead to referral to a dermatologist.

A complete evaluation requires attention to all factors that might contribute to pruritus. Sensitivity to various medications should be considered. Recent laboratory test results should be reviewed. Although studies have found an association between insufficient clearance of toxins and itching, it is unlikely that underdialysis plays a significant role in most cases. There has traditionally been significant attention with pruritus to calcium, phosphorus, and PTH concentrations. It is unlikely that any of these play a role in pruritis, as discussed above.