Monday, April 18, 2011

Doc, this itching is making me crazy

Nearly every time I walk through the dialysis unit at the VA, at least one patient calls me over to tell me that their itchy skin is driving them crazy. Pruritus is a torment to many dialysis patients, and the best I’ve been able to offer to patients as far as management is: come to dialysis, stay the whole time, and watch your phosphorus intake. That’s pretty dissatisfying to many patients, especially when they are already doing all of those things.

More than half of all patients undergoing dialysis complain of pruritus, and the mechanism isn’t really very well understood. Some studies have found no significant difference in serum levels of creatinine, BUN, calcium, phosphorus, alkaline phosphatase, PTH, and hematocrit in patients with pruritus vs without, but the general recommendation is to keep phosphorus and PTH under good control. One study did find a significant difference in the frequency of neuropathy in patients with pruritus, and another found an association with hemoglobin A1c.

Trials investigating treatment options have not yielded a cure, but treatments are out there, and include topical therapies such as emollients, capsaicin, gamma-linolenic acid, and tacrolimus, systemic therapies such as activated charcoal, gabapentin, pentoxyfilline, and thalidomide, and physical therapies like UV phototherapy, electroacupuncture, and renal transplantation. First and foremost, management involves ensuring the patient is adequately dialyzed and their calcium/phosphorus and PTH levels are well controlled. A flow chart (I love flow charts) is found in this article.

In the patient with severe refractory itching, a diagnosis to consider is Kyrle’s disease, or perforating folliculitis. Kyrle’s disease is associated with diabetes and CKD/ESRD- one series found 9 cases in 200 dialysis patients, and is an odd disorder wherein keratin, collagen, and elastic fibers migrate transepidermally. The lesions are small papules that are flesh colored or slightly hyperpigmented. They slowly enlarge with time and each one contains a central, keratotic, slightly depressed core. This core contains a plug filled with keratin, parakeratotic scale, and basophilic debris. The epidermis around the core is thinned, and the plugs can contact the dermis and become inflamed. Treatment is difficult, but some success has been noted with tretinoin creams (though these should be used with caution in dialysis patients due to risk of high vitamin A levels), avoidance of trauma and scratching- ie wearing gloves, trimming fingernails, and transcutanous nerve stimulators. Large lesions can be excised, and phototherapy has been particularly successful for dialysis patients. Occasionally, patients are cured with renal transplantation. I had a patient recently who was severely affected by pruritus and had been treated for everything from scabies to psychiatric disease. We diagnosed her with Kyrle's disease after a skin biopsy, and although the therapies were not immediately effective in eliminating the itching, it was some relief to her to put a name to her symptoms.


Tom Oates said...

Great idea for a post. There has been reasonable success with HDF reducing itch compared to standard high flux HD.
I practice in the UK & hear that HDF is not really much used outside of the ICU in the US - is that true?

emily petersen said...

That's interesting- it's true at least here in Utah that we don't use HDF except in the ICU. I'll have to check and see if our machines are even set up for it. Do you use HDF regularly in the UK?

Gearoid McMahon said...

HDF is being increasingly used in dialysis unit in Europe but bot so much in the US. It is much more expensive as it requires ultra-pure water treatment. Even in the ICU, most units use hemofiltration only, as far as I know, there is no really convincing evidence that HDF is better than HF.

I had some experience with HDF before I came to the US and the patients who were switched said they felt better at least althogh there were no objective data suggestiong better clearance etc.

Tom Oates said...

Thanks guys
I feel a post coming on...

emily petersen said...

I have talked to a few people about HDF and our machines aren't set up to do that. My understanding is that it is cost prohibitive to do the ultra pure water treatment or bagged replacement fluid. We do pretty much exclusively HDF in the ICU for our continuous patients, but the current cost-cutting environment in outpatient dialysis units probably means that we won't be seeing outpatient HDF here anytime soon.

Anonymous said...

I was on home hemo and had an angiogram on my fistula. They used iodine contrast and a day after the angiogram I had horrible itching all over my body. Went to a dermatologist got a biopsy and was diagnosed with pruitis. The itchig would get worse when doing my dialysis. My nephrologost suggested I run one liter of saline thru the machine before I start dialyzing. This helped a lot but did not stop the pruitis. Had a kidney transplant and the itching and all the lesions and scabs were gone within a week. No more itching!!
The itching can drive you crazy. Sarna was a nice very temporary lotion that helped a little. I wish you all the best!

iain said...

HDF rocks.

Anonymous said...

To avoid itchiness and reactions,try a steam-sterilized dialyzer like the Polyflux Revaclear from Gambro. E-beam and gamma sterilized dialyzers will always have some residual particles from the manufacturing process, even if the staff is recirculating and/or flushing saline.

Anonymous said...

Why don't American dialysis patients get the benefits of the use of ultra-pure water when Australian and European dialyzors do? Why can they afford it but we cannot? How do you feel when you KNOW your dialysis patients aren't getting the best treatment that technology has to offer? I would really hate to have to work in a dialysis clinic knowing that some bureaucrat has decided that my patients don't deserve ultra-pure water. Must be very hard for you, truly.

Farhan said...

Hey guys, just got back from the spring clinical NKF meeting in vegas. Dr. Rajiv Agarwal did a literature review of dialysis papers in 2010. He basically gave a top 10 of 2010. He included an interesting article that I have posted the link to below. Basically it's a randomized, double blinded, placebo controlled trial of Nalfurafine, A kappa receptor agonist, that showed a significant decrease in pruritus. The only issue was insomnia associated with the medication, but with reduced dose of 2.5mg the insomnia prevalence decreases.

Leslie F. said...

Hi, my husband a dialysis patient for 2 years was just diagnosed with Kyrle's disease yesterday by a Dermatologist. It is very extensive on his body. After suffering with severe itching and pain that was driving him, (and me) crazy for almost a year. He said the pain after the itch was like having a splinter deep in you finger multiplied hundreds of times. Hopefully Vitamin A cream will give him some relief. Unluckily at this point I'm not surprised that HDF is not used in the US except in ICU's
and only HD is used. Considering the obscene amount of money that US dialysis treatment centers are receiving for each dialysis treatment given for patients on disability for renal failure. They have TV's for each patient. Let's scrap the TV's...and get HDF instead ok? Personally I do think that the large dialysis companies in the US, do certainly have enough money for HDF. But maybe the greedy "higher ups" are more worried about padding their yearly bonuses. It's not about the patient in dialysis clinics here in the US. It is about how much money the clinics can milk out of a renal patient before they die. That may seem bitter and too hard core but it is true honestly. That does not mean that there are not very good Drs. and caring technicians here because there are many but corporate medicine has a strangle hold on America and it may well bankrupt us all. My husband will not live to see good, fair socialized medicine in the US, and I would have to emigrate out of this country to receive it. But I hope my children and grandchildren have fair, civilized un-rationed by the insurance companies,socialized medicine in the US.

Rafay Aziz said...

Hello Guys

I am Rafay Aziz From Pakistan My Mother is a Dialysis Patient and i am using a dialyzer with Uf coefficient of 18 and effective surface area of 1.8 m2

My mother's Problem is she is having sever itching but not pain which is making her almost crazy i need your help please do tell me what should i do i am using every method like itching creams attarax tabs and many more anti allergy tabs

She feels like burning on her skin sometime

Please do let me know what can i do for her i will be very thank full to all

My email id is
rafay_aziz_3 @ hotmail