#6113 SCRATCHING THE SURFACE? A LONGITUDINAL OBSERVATIONAL STUDY ON PRURITUS AND ITS CURRENT TREATMENT IN INCIDENT DIALYSIS PATIENTS
Authors: van Lieshout Thomas Sebastiaan , de Ruijter Violette , de Lange Sanne , Driehuis Esmee , Vernooij Robin , Rustemeyer Thomas , Abrahams Alferso C , Van Jaarsveld Brigit 
Published: June 2023

Abstract

Background and Aims
Chronic kidney disease-associated pruritus (CKD-aP) is a common condition in dialysis patients. It is associated with impaired health-related quality of life (HRQoL) and sleep disturbances. The pathophysiology remains unclear resulting in limited treatment options and lack of treatment guidelines. The exact course of CKD-aP after dialysis initiation has not been identified nor the state of current medical treatment. Therefore, the aim of this study was to assess presence and severity of CKD-aP during the first year of dialysis, and to assess how it is currently medically managed.

Method
Data were used from the ongoing multicentre, prospective, observational Dutch nOcturnal and hoME dialysis Study To Improve Clinical Outcomes (DOMESTICO). This study longitudinally compares HRQoL between different dialysis modalities. Incident dialysis patients (&gt; 18 years) were included, if they completed a HRQoL questionnaire around initiation. Pruritus was assessed using the Dialysis Symptom Index (DSI), using a 5-point Likert scale. Medication data were retrieved from electronic patient files. Outcome parameters were prevalence, severity of pruritus and the use of antipruritic medication, both systemic and topical, all measured at dialysis initiation and after 3,6 and 12 months. The association between pruritus and treatment was studied using logistic regression analysis and adjusted for potential confounders.

Results
A total of 643 patients were included, 70.8% started with hemodialysis and 29.2% with peritoneal dialysis. The mean (SD) age was 64.0 years (13.8) and 68.3% were men. At dialysis initiation 53.5% of all patients suffered from pruritus with a fluctuation in prevalence following the first year of dialysis (Fig. 1). During the first year 35.7% of the patients had persistent itching, 35.5% had fluctuating itching and 28.8% never experienced itching. There was a small increase in number of patients without itching at 3 months followed by an increase in number of patients with ‘quite some itch’ to ‘severe itch’ over the next months (Fig. 2). At 6 months after start dialysis 10.8% of the dialysis patients received topical antipruritic treatment, 17.2% received systemic antipruritic treatment and 3.3% received both topical and systemic treatment. The majority of patients with topical antipruritic treatment received emollients (58.9%) followed by cutaneous steroids (37.6%). Systemic steroids were the most used systemic antipruritic treatment (58.7%), followed by antihistamines (20.4%) and gabapentoids (17.4%). Patients treated with topical agents at 6 months showed an odds ratio of 3.48 (95%CI: 1.11 – 10.91) on severe itching compared to patients without treatment. Furthermore, patients with systemic antipruritic treatment and with both systemic and topical treatment showed an odds ratio of 1.40 (95%CI: 0.48 – 4.03) and 1.52 (95%CI: 0.41 – 5.70) compared to patients without treatment respectively.

Conclusion
CKD-aP is highly prevalent in incident dialysis patients. The presence of CKD-aP is fluctuating during the first year of dialysis, with a third of patients experiencing intermittent itching. Starting dialysis may have a small beneficial effect on presence and severity of CKD-aP, but this is lost over time with moderate to severe CKD-aP increasing over the following months. Approximately a third of the patients received treatment for CKD-aP, predominantly as systemic treatment. The use of topical antipruritic treatment is associated with more severe CKD-aP at six months after start dialysis. These findings emphasize the need for further research on the pathophysiology and optimal treatment in dialysis patients.