New Option For Difficult
Pam Harrison
WASHINGTON, DC The intensity of itch experienced by patients on hemodialysis with uremic pruritus can be eased with 12 weeks of treatment with difelikefalin , results from the phase 3 KALM-1 study show.
“For the first time in my career, which has been filled with negative studies trying to improve uremic pruritus,” we have a drug “that was effective and well tolerated,” said investigator Steven Fishbane, MD, from Northwell Health in Great Neck, New York.
This is a really difficult-to-treat population of patients. Difelikefalin comes in on “what, right now, is a blank space. There just isn’t anything that we have that works well in this regard,” he said during a news conference here at Kidney Week 2019.
The study was also simultaneously published in the New England Journal of Medicine.
It is estimated that at least 40% of patients with end-stage renal disease suffer from pruritus. Currently, the only approved treatment is an antihistamine, such as Benadryl. Ultraviolet light therapy also helps, but having patients go for light therapy on top of doing dialysis 3 days a week is simply a lot to ask, said Fishbane, who has served as a consultant for and received research fees from Cara Therapeutics.
Uremic pruritus is a significant problem for many patients on hemodialysis, and it clearly affects their quality of life, said Pascale Lane, MD, from the University of Oklahoma Health Sciences Center in Oklahoma City, who chaired the news conference.
Itching And Kidney Disease
A recent survey of people on hemodialysis found that itching, also known as chronic kidney disease-associated pruritus or CKD-aP, was common, with 61% self-reporting the itch was at least somewhat intense and 25% reporting it was very or extremely intense. About half of those surveyed also said that pruritus led to skipped or shortened hemodialysis sessions.
What causes the itching, and what can be done to stop it? Three people living with kidney disease and pruritus are here to share their experiences and offer hope to others in a similar situation: Jen Trunk, Alex Barrios, and Dawn Edwards.
Alteration Of Dialytic Treatment
There is evidence from randomized studies to suggest that high-flux HD is superior to low-flux for CKD-aP and that haemodiafiltration may be superior to high-flux HD . The addition of haemoperfusion may also provide additional benefit . Methodological flaws limit the strength of these observations but further study is warranted.
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The Challenge Of Unifying Disparate Observations
The pathophysiology of CKD-aP remains unclear. There is no single overarching theory of mechanism. Without that clarity, a coherent approach to management is made more difficult. Currently, our understanding of the pathophysiology derives from multiple disparate sources, with many gaps and some contradictions. These sources include the epidemiological associations between CKD-aP and other features of advanced CKD, the multiple isolated observations of disturbance to the immunochemical milieu of the skin in CKD-aP and associated serum biomarkers, and inferences regarding pathophysiology based on our expanding knowledge of basic itch science and the pharmacological action of effective treatments of CKD-aP. These observations, from different fields, will, no doubt, eventually form a part of a unified hypothesis of mechanism. In the next sections, we will address these areas in detail by first summarizing the literature on the conventional associations made with CKD-aP, then synthesizing the diverse descriptions of immunochemical changes in the skin of patients with ESKD and CKD-aP compared to those without CKD-aP, and finally summarizing the evidence of management strategies.
Where Does Kidney Itch Occur
Bernadette Caldwell | Answered February 27, 2020
Itching with kidney disease can be generalized, or it can occur in specific parts of the body. Common areas for this type of itching include the head, arms, back, and abdomen. It also tends to be worse at night, which can disturb your sleep.Oct 20, 2021
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How Will Itching Affect Me
Itching is unique to everyone. It may be continuous or come and go as you attend dialysis. It could only affect parts of your body, such as the arms and legs, or the entire body. The itch may feel internal, like something crawling under the skin.
Itching may lead to fatigue when it occurs at night. It could reduce your sleep quality, making you less productive on some days. You may also experience mood changes due to poor sleep. Itching can affect your social life in cases where it makes you restless.³
Itching could affect the appearance of your skin it can look dry and crack easily. The cracks may also bleed in some cases. Scratching may also expose you to higher infection risks since germs can easily reach your blood.
Shortness Of Breath After Very Little Effort
Why this happens:
Being short of breath can be related to the kidneys in two ways. First, extra fluid in the body can build up in the lungs. And second, anemia can leave your body oxygen-starved and short of breath.
What patients said:
At the times when I get the shortness of breath, it’s alarming to me. It just fears me. I think maybe I might fall or something so I usually go sit down for awhile.
I couldn’t sleep at night. I couldn’t catch my breath, like I was drowning or something. And, the bloating, can’t breathe, can’t walk anywhere. It was bad.
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What Stage Of Kidney Disease Causes Itching
Kidney disease is categorized into five stages based on its severity.
Itching is often associated with stages 4 and 5. However, depending on your body’s reaction to factors such as treatment, it could occur at any stage. The American Academy of Dermatology notes that itchy skin may be common in later stages of CKD. It is best to consult a doctor since itchy skin is not the only indicator of advanced kidney disease.
How Common Is Itching In Kidney Disease
Itching in kidney disease is most common in those on dialysis. Between 20 and 50 percent of hemodialysis patients will experience pruritus in CKD. This is an improvement from the early days of dialysis. Back then kidney failure itching would affect 100 percent of those undergoing dialysis.
A study in the Acad Dermatol Venereol journal found that itching after dialysis is also more common among men than women.
There are also cases in people who are not on dialysis. Itching is typically a kidney failure symptom, but stage 3 kidney disease and itching have also been seen. So even if you are not on dialysis, the renal itch is an important symptom to look out for. It can tell if your CKD is progressing.
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Kidney Disease Rash Treatment
Treatment for a kidney disease rash will vary based on its type and cause.
Acquired perforated dermatosis does not have many well-studied treatments. However, a 2014 study reported that some creams and oral medications have been effective. As have and cryotherapy with liquid nitrogen.
Treating the white bumps caused by calcium deposits is done by reducing the intake of phosphorus. Foods high in phosphorus are dairy products, fish, chicken, lentils, cashews, and potatoes. When phosphate blood levels go back to normal, the bumps usually go away on their own.
Uremic pruritus has several treatment options available. They include:
- Family history of kidney disease
Feeling Faint Dizzy Or Weak
Why this happens:
Anemia related to kidney failure means that your brain is not getting enough oxygen. This can lead to feeling faint, dizzy, or weak.
What patients said:
I was always tired and dizzy.
It got to the point, like, I used to be at work, and all of the sudden I’d start getting dizzy. So I was thinking maybe it was my blood pressure or else diabetes was going bad. That’s what was on my mind.
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Who Gets Uraemic Pruritus
The prevalence rates of uremic pruritus are between 2050% in those with chronic kidney disease, however, the reported rates appear lower in children at approximately 9%.
Uraemic pruritus is not associated with sex, age, ethnicity, duration of dialysis, or cause of renal failure. Pruritus does not arise when uraemia is due to acute renal failure.
Why Does Kidney Disease Cause Itching
Itchy skin in kidney disease is sometimes referred to as uremic pruritus or chronic kidney disease associated pruritus. A build-up of urea in the blood causes the itch, which occurs when both kidneys stop working. It is a problem in a third of people on dialysis and is more common in hemodialysis than in continuous ambulatory peritoneal dialysis .
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More Itching Treatment Options For Ckd Patients
Itching can be difficult to treat and you may need to try different treatments before you find one that works for you. If the above suggestions haven’t helped, you can talk to your doctor about possible medicines including:
Gabapentin or pregabalin: These medicines can reduce itching by affecting how your nerves work. They can also make you sleepy and dizzy and the dose must be carefully monitored.
Sertraline: This is a type of anti-depressant called a selective serotonin reuptake inhibitor . It may reduce your itching but can take a while to have an effect.
Phosphate binding medications: These medications lower your blood phosphate levels. However, it is debatable whether they help with itching. If your doctor has advised you that you need these then you should continue their use.
Oral antihistamines: These are often tried for itching. However, the mechanism of itching associated with kidney disease is different from allergic itching and so antihistamines are usually not effective. Antihistamines can make you feel tired so if you do try them, it is best to take them before you do to bed to help you sleep. You should avoid using them if you are planning to drive or use machinery.
Some of the medicines above are not licensed for use for itching and it is important to discuss this with your doctor before trying them.
You should always follow your healthcare teams advice regarding medications.
What Does Kidney Failure Skin Look Like
Wanda Holloway | Answered August 22, 2021
You may notice a gray or yellow hue to your skin, areas of darkened skin, or an unhealthy pale tone. If youve had itchy skin for a long time and scratch often, you may also see yellowish, thick skin with bumps or cysts. Discolored nailskidney disease can affect the look of your fingernails and toenails.
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What Are The Clinical Features Of Uraemic Pruritus
Itch in uremic pruritus most commonly affects the back, however, it can also involve the arms, head, and abdomen. Generalized pruritus is also noted in a proportion of affected patients .
Other characteristic features include:
- Itch becoming worse at night, often resulting in disruption of sleep
- Exacerbation of itch with heat and stress
- Relief of itch with physical activity, cooler temperatures, and hot or cold showers
- Fluctuation of symptoms during haemodialysis sessions.
Uraemic pruritus can be associated with several non-specific cutaneous features resulting from repetitive scratching.
These may include:
Fatigue Being Tired All Of The Time
Why this happens:
Healthy kidneys make a hormone called erythropoietin , or EPO, that tells your body to make oxygen-carrying red blood cells. As the kidneys fail, they make less EPO. With fewer red blood cells to carry oxygen, your muscles and brain tire very quickly. This is anemia, and it can be treated.
What patients said:
I was constantly exhausted and didn’t have any pep or anything.
I would sleep a lot. I’d come home from work and get right in that bed.
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Advice From Those Living With Ckd
Living with kidney disease and pruritus can be incredibly challenging, but Alex, Dawn, and Jen want you to know there is hope.
“I will tell those with this condition to not give up or lose hope. Know that you aren’t crazy. This is a true condition that will impact your life,” Alex said. “It is a discussion that definitely needs to be had with your care team and your family. Continue to be your best advocate and you’ll see some relief but it’s not going to be perfect.”
As your own advocate, don’t be afraid to push your healthcare team to find and try new solutionsespecially if what you’re experiencing isn’t properly addressed.
“Whether you have itching or you’re in pain, it’s something that you should talk to your care team about. That’s very important and it’s a part of staying healthy. Talk to your doctors if you’re having problems, said Dawn. Be open, honest, and don’t give up. If they haven’t addressed your problem, go back and ask them again. Don’t stop asking until you receive some type of resolution.”
Finally, talk about what you’re experiencing with others. You may find it helpful to be with a community of people who understand or find new treatment ideas to bring to your healthcare team’s attention.
Upset Stomach Nausea Vomiting
Why this happens:
A severe build-up of wastes in the blood can also cause nausea and vomiting. Loss of appetite can lead to weight loss.
What patients said:
I had a lot of itching, and I was nauseated, throwing up all the time. I couldn’t keep anything down in my stomach.
When I got the nausea, I couldn’t eat and I had a hard time taking my blood pressure pills.
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Skin Problems And Dialysis
Some patients with chronic kidney disease who are on dialysis may notice some unpleasant changes in their skin. Three skin conditions that sometimes affect those on dialysis include itching , dry skin and skin discoloration . Learning why these skin conditions happen, and what can be done to prevent or ease the problem, can help keep skin as healthy as possible.
Itching
A majority of dialysis patients, whether they do hemodialysis or peritoneal dialysis , may experience itching at some point. Some feel itchy all the time, while for others it comes and goes. Many say itching is worse during or just after treatment. For some people the itching is in one area, while others feel itchy all over.
A common cause of itching is a high level of phosphorus in the body. Because dialysis doesn’t effectively remove phosphorus, a renal diet that limits foods high in phosphorous is prescribed. Additionally, taking phosphorus binders with every meal and snacks can help. Try to maintain a phosphorus level at 5.5 or less. Staying on dialysis for your full treatment time is also recommended, because it can remove some phosphorus as well as other wastes and toxins.
Allergies can cause itching. If you notice itching occurs at the beginning of dialysis treatments, you could have an allergy to the blood tubing, dialyzer , the type of heparin being used or other elements associated with the treatment.
Check with your doctor before trying any anti-itch method or product.
Dry skin
Skin discoloration
Dehydration And Dry Skin
People with ESRD often have dry skin, but the connection between dry skin and itching is not so clear. What has been determined is that dry skin makes the itching worse and more severe.
Getting less fluid can cause itchy skin to get worse. Hydration is important for kidney health especially if you are on dialysis. The fluid removed during dialysis needs to be replenished. So getting enough hydration between treatments could help lessen the intensity of the itch.
Dry skin becomes dangerous when it turns into nephrogenic systemic fibrosis . This condition results in the hardening of the skin causing it to become thick and tight. It also can scar the lungs and kidneys. Too much gadolinium causes this condition. Kidney patients are exposed to this during imaging and dialysis expose kidney patients to this compound. NSF is also responsible for kidney itch.
Some people with kidney disease also have nerve damage that prevents them from sweating enough. This could lead to dry skin and is another reason to keep hydrated.
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How Dermatologists Help Patients With Kidney Disease
Kidney doctors, called nephrologists, often care for patients with kidney disease. When a kidney disease affects the skin, a nephrologist may team up with a dermatologist. Some skin conditions that develop due to kidney disease can be difficult to control. For example, if a patient has extremely itchy skin, it may be impossible to sleep through the night. A board-certified dermatologist can help a patient get some relief. This may involve using the right balance of moisturizers and medication that you apply to the skin. Some patients get relief with a treatment called UVB phototherapy.
The right skin care may also help. If the kidney disease is causing extremely dry skin, these tips from dermatologists may help:
1 Centers for Disease Control and Prevention. Chronic kidney disease in the United States, 2019. Page last reviewed Mar. 11, 2019. Last accessed Feb. 27, 2020.
ImagesImage 1: Image used with permission of the American Academy of Dermatology National Library of Dermatologic Teaching Slides.
Images 2, 3, 6, 9, 10: Getty Images
Images 4, 5, 7, 8, 11: Journal of the American Academy of Dermatology
ReferencesAmin A, Burgess EF. Skin manifestations associated with kidney cancer. Semin Oncol. 2016 43:408-12.
Centers for Disease Control and Prevention. Chronic kidney disease in the United States, 2019. Page last reviewed Mar. 11, 2019. Last accessed Feb. 27, 2020.
Galperin TA, Cronin AJ, et al. Cutaneous Manifestations of ESRD. Clin J Am Soc Nephrol. 2014 9:201-18.
Food Tastes Like Metal
Why this happens:
A build-up of wastes in the blood can make food taste different and cause bad breath. You may also notice that you stop liking to eat meat, or that you are losing weight because you just don’t feel like eating.
What patients said:
Foul taste in your mouth. Almost like you’re drinking iron.
I don’t have the appetite I had before I started dialysis, I must have lost about 10 pounds.
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