II. Epidemiology of Pruritus in Chronic Renal Failure

  1. Pruritus affects 40-86% of Hemodialysis patients
  2. Affects 25% of non-dialysis Renal Failure patients
  3. Provocative
    1. Worse in summer
    2. Variable association with Dialysis timing

III. Pathophysiology

  1. Proposed Mechanisms specific to Renal Failure
    1. Secondary Hyperparathyroidism and Hypercalcemia
    2. Hyperphosphatemia
    3. Aluminum overload
    4. Mast cell proliferation
    5. Plasma histamine level increases
    6. Sebaceous Gland atrophy
    7. Eccrine Sweat Gland atrophy
    8. Microangiopathy
  2. Other Mechanisms from comorbid conditions
    1. Peripheral Neuropathy
    2. Dry Skin

IV. Symptoms

  1. Itch occurring in severe paroxysms
  2. Localized in 56% and generalized in 44% of patients
  3. Associated with decreased quality of life (depressed mood, Insomnia)

V. Differential Diagnosis

  1. See Pruritus
  2. Consider other causes in severe, refractory Pruritus

VI. Management

  1. General measures
    1. Hypoallergenic Skin Lubricant applied 2-4 times daily
    2. Topical anesthetic
      1. Pramoxine (CeraVe itch relief)
      2. Topical Capsaicin 0.0255%
    3. Gabapentin 100 mg after each Dialysis session
      1. Rayner (2012) Nephron Clin Pract 122(3-4):75-9 +PMID:23548570 [PubMed]
  2. Other treatments that have been effective
    1. Ultraviolet (UV) Light Therapy
      1. Ultraviolet B
      2. Ultraviolet A with Psoralen (PUVA)
    2. Polidocanol (balneotherapy)
    3. Activated Charcoal 6 grams per day
    4. Cimetidine
    5. Cholestyramine
  3. Ineffective therapies
    1. Poor response to Antihistamines
    2. No relief with Naltrexone
    3. No relief with Ondansetron
    4. No relief with phosphorus binding or other phosphorus lowering

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