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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 6  |  Issue : 1  |  Page : 5-9

Frequency and possible pathogenesis of chronic renal failure-associated pruritus in dialyzed patients


Department of Internal Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt

Date of Submission28-Apr-2020
Date of Decision15-Jun-2020
Date of Acceptance15-Jun-2020
Date of Web Publication25-Sep-2020

Correspondence Address:
Mohamed A Sobh
Professor of Internal Medicine - Faculty of Medicine / Assiut University, Assiut
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCMRP.JCMRP_51_20

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  Abstract 

Background
Uremic pruritus is a common dermatological problem in patients on hemodialysis. The pathogenesis is not fully understood; it is a multifactorial infection. The aim of this study was to identify the frequency of pruritus in patients with chronic renal failure on hemodialysis and its association with serum electrolytes (Ca and P), level of parathyroid hormones (PTH), and dialysis adequacy.
Patients and methods
A total of 60 patients with chronic renal failure on hemodialysis were included in the present study from dialysis unit in the Faculty of Medicine, Assuit University Hospital. Data were collected according to a structural questionnaire, including age, sex, and duration of dialysis. The authors investigated sociodemographic data, and several biochemical tests, such as calcium, phosphorus, kidney functions, and PTH, were performed to know their association with uremic pruritus. All patients,from them is corrected and deleted it so the sentence become as follow: A detailed description of the study and written informed consent was obtained. The study was registered with IRB no.17101062.
Results
This study revealed that the prevalence of pruritus was higher in males than females, and also, there was no association with age. Of all biochemical tests, phosphorus, PTH, and duration of dialysis showed significant association with pruritus (P=0.043, 0.000, and 0.030, respectively). The association between PTH and the other study variables showed that significant association with calcium (P=0.012). The dialysis adequacy showed no significant association with other variables.
Conclusion
Uremic pruritus is a common problem, occurring in ~64.9% in patients with chronic kidney disease on hemodialysis. In this study, the authors found that increase in PTH level, increase in serum phosphorus, dialysis adequacy, and xerosis play a major role in pathogenesis of renal pruritus. The authors recommend from this study regular follow-up of patients treated for more than 6 months with hemodialysis, with regular measurement of PTH level and serum phosphorus and their proper management to prevent appearance of renal pruritus and use of novel approaches such as tacrolimus ointment, oral activated charcoal, phototherapy, acupuncture, and kidney transplantation.

Keywords: parathyroid hormones, pruritus, hemodialysis, uremic, electrolytes, urea reduction ratio


How to cite this article:
Sobh MA, Sayed DG, A. Elzohri MH. Frequency and possible pathogenesis of chronic renal failure-associated pruritus in dialyzed patients. J Curr Med Res Pract 2021;6:5-9

How to cite this URL:
Sobh MA, Sayed DG, A. Elzohri MH. Frequency and possible pathogenesis of chronic renal failure-associated pruritus in dialyzed patients. J Curr Med Res Pract [serial online] 2021 [cited 2021 Apr 19];6:5-9. Available from: http://www.jcmrp.eg.net/text.asp?2021/6/1/5/296149


  Introduction Top


Globally, kidney disease affects more than 750 million persons. It is a known public health problem [1]. Chronic renal failure (CRF) is defined according to the degree of kidney damage and loss of function over a period of months or years. All individuals with glomerular filtration rate less than 60 ml/min/1.73 m2 for 3 months or more are categorized as having chronic kidney disease[2] Kidney failure is also called end-stage renal disease. Patients on hemodialysis, have moderate to severe pruritus, often feel depressed and drained, have a 17% higher mortality rate, and have a poor quality of sleep [3]. There are several causes of CRF such as diabetic nephropathy, hypertension, glomerulonephritis, interstitial nephritis, pyelonephritis, polycystic kidney disease, and obstructive nephropathy [4]. CFR is linked to several complications, including electrolyte disturbances (hyperphosphatemia and hypocalcemia), hyperparathyroidism, anemia, and cutaneous complications (uremic pruritus) [5].

Uremic pruritus is one of the most frequent and burdensome symptoms in patients with kidney failure, affecting up to 46% of hemodialysis patients [6]. Uremic pruritus can be a generalized or localized itch affecting the back, face, and arms [7]. Uremic pruritus has a multifactorial pathogenesis and is associated with physical disability, impaired quality of life, and mental limitations, such as anger, anxiety, and depression [8–10]. Uremic pruritus has been recognized as a fundamental research priority among the patients with kidney disease [11]. The actual mechanism of uremic pruritus and its association with CRF is poorly understood, but there are number of suspected causes that may play a role in the development of pruritus in patients with CRF such as hyperphosphatemia, hyperparathyroidism, immunohypothesis (interleukin-2 and interleukin-6), opioid hypothesis, histamine and serotonin receptors, inadequate removal of uremic toxins by dialysis, and neuropathic changes [12].

The main objective of the present study was to explore the frequency and possible relation between pruritus in patients with CRF on hemodialysis and different laboratory parameters such as serum electrolytes (Ca and P), level of parathyroid hormones (PTH), and dialysis adequacy that may help in understanding the pathogenesis of uremic pruritus.


  Patients and? methods Top


Study design and population

This cross-section study was conducted at the hemodialysis unit of the internal medicine department Assiut University. A total of 60 patients with CRF on hemodialysis for more than 6 months were included. Patients were divided into two group: group I included 30 patients with CRF with pruritus, and group II included 30 patients with CRF without pruritus. Inclusion criteria were patients with CRF and pruritus diagnosed by nephrologists. Exclusion criteria were patients with primary skin disease, cholestatic liver disease, acute hepatitis, parasitic infections, and malignancy. A detailed description of the study and written informed consent was registered with IRB No.17101062.

Data collection

The fundamental demographic and clinical data were collected by using a questionnaire containing several variables such as age, sex, duration of hemodialysis, assesses degree of skin affection as scratch marks, ulcers, and secondary infections to obtain information that would be of help to the study.

Biochemical testing

A number of biochemical tests for patients and controls were performed on the blood samples such as complete blood count, serum electrolytes (Ca+ and P+), PTH level, and dialysis adequacy using urea reduction ratio (URR), which were measured according to their respective kits' and manufacturers' instructions and their universal equations.

Statistical analysis

Statistical analysis was performed using statistical Package for the Social Sciences Version 16.0 for Window software (SPSS Inc. was a software house headquartered in Chicago and incorporated in Delaware). Mean and SD were used to express quantitative data. For continuous variable, testing between two groups was performed by the Mann–Whitney U-test. Categorical variables were compared by Pearson χ2 test when very small proportions were analyzed. Correlations among continuous variables were calculated by the Spearman rank correlation coefficient (rs). P values of less than 0.05 were considered statistically significant.


  Results Top


Sociodemographic and clinical characteristics

?Our study was conducted on the prevalence of chronic kidney disease-associated pruritus in the dialysis unit of internal medicine department of Assiut University Hospital and found the prevalence was 64.9% [Figure 1]. The mean ± standard deviation (SD) age was 44.30 ± 14.15 years for group I and 48.10 ± 17.65 years for group II. Males represented 17 (56.7%) and 13 were (43.3%) females in group I, and 18 (60%) were males and 12 (40%) were females in group II. A total of 20 (66.6%) patients in group I experienced xerosis or dry skin on clinical examination compared with 15 (50%) patients in group II. In group I, pruritus was severe generalized in five (16.6%), moderate in all extremities in 15 (50%), and mild limited to legs only in five (33.3%). The clinical diagnosis for any chronic diseases present was collected and is? summarized in [Table 1].
Figure 1: Prevalence of chronic kidney disease.associated pruritus in the Dialysis Unit of Internal Medicine Department of Assiut of University Hospital.

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Table 1: Sociodemographic data and clinical characteristics of patients with chronic renal failure on hemodialysis with and without pruritus

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Duration of hemodialysis and biochemical parameters

[Figure 1] shows the prevalence of chronic kidney disease-associated pruritus in the dialysis unit of internal medicine department of Assiut University Hospital.

[Figure 2] shows the duration of hemodialysis for both groups. In group I, the mean duration was 5.88 ± 3.28, and it was 4.19 ± 2.61 in group II, with significant association (P = 0.030). In addition, measurements of electrolytes including calcium and phosphorus levels were performed and represented in [Table 2]. The me?an hemoglobin level for both group I and group II was 9.87 ± 1.75 and 9.20 ± 1.38, respectively, without significant association with pruritus (P = 0.91). Assessments of PTH were performed and showed highly significant association with presence of pruritus (P = 0.000) [Figure 3]. The correlation between PTH in both groups and the other study variables was performed and showed varied positive and negative correlation. The correlation was not statistically significant, except for calcium, which showed a negative correlation with significant association (P = 0.012) in group I only. Data are summarized in [Table 3].
Table 2: Serum electrolytes in patients with chronic renal failure on hemodialysis with and without pruritus

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Figure 2: Mean duration of dialysis for patients with and without pruritus.

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Table 3: Correlations of parathyroid hormones level with other variables in patients with chronic renal failure on hemodialysis with and without pruritus

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Dialysis adequacy as determined by URR was performed and showed lower value in group I, with mean ± SD of 64.53 ± 4.57, than in group II, with positive correlation detected between dialysis adequacy by URR and pruritus [Figure 3] and [Figure 4]. Moreover, the correlation of dialysis adequacy and the other variables was performed and is? summarized in [Table 4].
Figure 3: Parathyroid hormones level in patients with chronic renal failure on hemodialysis with and without pruritus.

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Figure 4: Mean dialysis adequacy in patients with chronic renal failure with and without pruritus.

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Table 4: Correlations of dialysis adequacy with other variables in group II (patients with chronic renal failure without pruritus)

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  Discussion Top


Dermal symptoms such as itching is associated with CRF, which cause changes in quality of life, anxiety and depression symptoms, which increase the morbidity risk [13]. The association between the dermal symptoms and morbidity rate in renal patients showed that patients with pruritus have a high morbidity rate of 23% more than the patient without itching [13]. Our study aimed to identify the prevalence and association between pruritus in patients with CRF on hemodialysis and several laboratory tests, such as serum electrolytes (Ca and P), level of PTH, and dialysis adequacy to help in understanding the pathogenesis of uremic pruritus.

In the present study, the prevalence of pruritus was slightly higher in males than females. The difference in pruritus prevalence according to sex was not statically significant (P = 0.793). Our study findings were in the line with Mistik et al.[14] and Pisoni et al. [15], who reported that males had a greater susceptibility of having pruritus from moderate to severe. This was in contrast with Szepietowski et al.[16] and Dar et al. [17], who reported a higher prevalence in females than males. In the present study, there was no significant association with age (P = 0.554). This result is in agreement with Suzuki et al. [5]. On the contrary, Weiss et al.[18] reported that the prevalence of pruritus has a higher prevalence in patients aged greater than 70?years. The difference may owing to our study population with pruritus having an age range fro?m 17.0 to 65.0 years. In the present study, there were several comorbidities in association with pruritus including hypertension, diabetes mellitus, and polycystic kidney disease, and significant association was showed in case of hypertension. Our study reported that there was a significant association between pruritus and dialysis duration, which agrees with previous studies [19],[20]. Our study findings showed that there were no significant associations between pruritus and kidney function parameters, including urea, creatinine, and estimated glomerular filtration rate as well as hemoglobin level. Moreover, the levels of calcium and phosphorus showed variation in patients with CRF with and without pruritus. The difference was significant between pruritus and phosphorus (P = 0.043), which agrees with Gatmiri et al. [21]. In the present study, PTH showed highly significant association with pruritus (P = 0.000). Our study findings are in agreement with Narita et al. [22], who reported a significant association between PTH levels and pruritus. The association between PTH and other study variables showed that only calcium has a significant association and negative correlation in patients with pruritus (P = 0.012). In our study, there was no significant association between hemoglobin level and pruritus. The dialysis adequacy in the present study showed no significant association with the other study variables.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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Kiliç Akça N, Tasçi S. Using nonpharmacological methods for controlled itch. TAF Prev Med Bull 2013; 12:1.  Back to cited text no. 8
    
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Ständer S, Stumpf A, Osada N, Wilp S, Chatzigeorgakidis E., Gender differences in chronic pruritus: women present different morbidity, more scratch lesions and higher burden. Br J Dermatol 2013; 168:1273–1280.  Back to cited text no. 9
    
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Attia EAS, Hassan AA. Uremic pruritus pathogenesis, revisited. Arab J Nephrol Transplant 2014; 7:91–96.  Back to cited text no. 12
    
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Kimata N, Fuller DS, Saito A, Akizawa T, Fukuhara S. Pruritus in hemodialysis patients: results from the Japanese Dialysis Outcomes and Practice Patterns Study (JDOPPS). Hemodial Int 2014; 18:657–667.  Back to cited text no. 13
    
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Mistik S, SUtas, A Ferahbas. An epidemiology study of patients with uremic pruritus. J Eur Acad Dermatol Venereol 2006; 20:672–678.  Back to cited text no. 14
    
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Pisoni RL, Wikström B, Elder SJ. Pruritus in haemodialysis patients: international results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrol Dialysis Transpl 2006; 21:3495–3505.  Back to cited text no. 15
    
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Szepietowski JC, Sikora M, Kusztal M. Uremic pruritus: a clinical study of maintenance hemodialysis patients. J Dermatol 2002; 29:621–627.  Back to cited text no. 16
    
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Weiss M, Mettang T, Tschulena U, Passlick-Deetjen J. Prevalence of chronic itch and associated factors in haemodialysis patients: a representative cross-sectional study. Acta DermVenereol 2015; 95:816–821.  Back to cited text no. 18
    
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Gatmiri M, Mahdavi-Mazdeh M, Lessan-Pezeshki M, Abbasi M. Uremic pruritus and serum phosphorus level. Acta Med Iran 2013; 51:477–481.  Back to cited text no. 21
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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