Renal Failure Associated Pruritus

Aka: Renal Failure Associated Pruritus, Uremic Pruritus, Chronic Uremic Pruritus

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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 Hydrochloride 1% (CeraVe itch relief)
        1. Young (2009) J Dermatolog Treat 20(2): 76-81 [PubMed]
      2. Topical Capsaicin 0.0255%
        1. Makhlough (2010) Iran J Kidney Dis 4(2): 137-40 [PubMed]
    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
    6. Montelukast (Singulair)
      1. Nasrollahi (2007) Iran J Kidney Dis 1(2): 73-7 [PubMed]
    7. Selective Serotonin Reuptake Inhibitors (Sertraline)
      1. Pakfetrat (2018) Hemodial Int 22(1): 103-9 [PubMed]
  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

VII. References

  1. (2017) Presc Lett 24(11): 62-3
  2. Ashmore (2000) Am J Kidney Dis 35(5):827-31 [PubMed]
  3. Combs (2015) Semin Nephrol 35(4):383-91 +PMID:26355256 [PubMed]
  4. Gilchrest (1982) Arch Dermatol 118(3):154-6 [PubMed]
  5. Kam (1996) Anaesthesia 51:1133-38 [PubMed]
  6. Pauli-Magnus (2000) Clin Nephrol 11(3):514-9 [PubMed]
  7. Ponticelli (1992) Nephron 60:1-5 [PubMed]
  8. Schwartz (2000) Semin Dial 13(3):177-80 [PubMed]
  9. Shirazian (2017) Int J Nephrol Renovasc Dis 10:11-26 +PMID:28176969 [PubMed]
  10. Szepietowski (1998) Int J Dermatol 37(4):247-53 [PubMed]

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