| Abstract|| |
Pruritus is commonly encountered in individuals with end-stage renal failure (ESRF) on dialysis. This study was performed in order to find out the prevalence and pattern of pruritus in patients on regular maintenance hemodialysis (HD) as well as to analyze its relationship to age, sex of the patient, site of itching and timing of hemodialysis. One hundred patients with ESRF (age ranging from 13 to 80 years) free from systemic, skin or psychiatric disorders and other secondary causes attributable to pruritis, undergoing maintenance HD (duration on HD 7-141 months; mean 49.9 and median 43 months) at Samtah General Hospital, Samtah, Gizan, Kingdom of Saudi Arabia were evaluated for pruritus on two occasions at one week interval by each author independently. The data were analyzed by simple descriptive statistics viz mean, median and chi-square test. Pruritus was observed in 27 of 40 males (67.5%) and 40 of 60 females (66.7%) with an overall prevalence of 67%. It was mild in 34 (50.8%), moderate in 22 (32.8%) and severe in 11 (16.4%). Sub-group analysis with reference to age and sex revealed that pruritus was significantly more in women aged 45 years and above, when compared with men of similar age-group (p < 0.05) or women below 45 years (p < 0.02). Pruritus was predominant in spinal dermatomes. Discomfort of pruritus was more during HD in three (two men and one woman) and HD gave relief for the day in 10 other individuals (four men and six women). Our study suggests that pruritus is observed in all age-groups and of both sexes of ESRF patients on HD although the intensity and site of itching and relationship to HD sessions varied with individuals.
Keywords: Pruritis, End-stage renal failure, Hemodialysis.
|How to cite this article:|
Jamal A, Subramanian P T. Pruritus among End-Stage Renal Failure Patients on Hemodialysis. Saudi J Kidney Dis Transpl 2000;11:181-5
|How to cite this URL:|
Jamal A, Subramanian P T. Pruritus among End-Stage Renal Failure Patients on Hemodialysis. Saudi J Kidney Dis Transpl [serial online] 2000 [cited 2020 Sep 27];11:181-5. Available from: http://www.sjkdt.org/text.asp?2000/11/2/181/36675
| Introduction|| |
Pruritus is a common symptom in uremic patients and is usually observed in the absence of visible skin lesions. , Pruritus is often distressing, recurrent or persistent, and may have an impact on the patients' overall well being.  The prevalence and pattern of pruritus seen among the dialysis population has varied in different studies. ,,,, Little research has been done on "renal itch"  despite its original description a century ago,  and nearly 70 years after the first investigation on this condition was carried out. 
The present communication tries to focus on certain clinical aspects of pruritus observed among patients in our institution on regular maintenance hemodialysis (HD). The study was undertaken to find out the prevalence and pattern of pruritus among our patients as well as to analyze its relationship with age, sex, site of itching and HD details. An attempt also was made to compare our observations with other published reports.
| Materials and Methods|| |
One hundred and forty eight patients received maintenance HD in Samtah General Hospital during the years 1418 and 1419H (1998-1999). Out of them, 100 patients were selected for the present study as they were clinically and manifestly free from the secondary causes of pruritus. ,,
In those cases where itching was confined to a localized area, appropriate assessment of the site was made with the help of a dermatologist or concerned specialist to rule out any local pathology. Exposure to environmental chemicals, pets or drugs, either at work-site or home, was excluded in these cases by detailed history. The underlying cause for end-stage renal failure (ESRF) was not known in most of the cases as they presented very late. However, three of the selected patients had chronic glomerular disease, four had obstructive uropathy and two had polycystic kidney disease.
All these patients received four-hourly sessions of HD twice per week using acetate bath and a hollow-fibre kidney containing polysulfone membrane. The duration on dialysis varied from seven to 141 months (mean 49.9 & median 43 months). Reuse of kidney and blood lines is not practiced in our center at any time.
All the study patients were informed about the proposed work individually (by A.J), and included for the study only after obtaining their consent to participate. The severity of pruritus as perceived by them was elicited clinically on at-least two occasions at an interval of one week by each author independently. When controversy arose in the observation, those patients were re-evaluated again after one week, in order to overcome inter- as well as intra-observer variation. The severity of pruritus was graded as mild, moderate, or severe as per Nielsen et al.  The patients were also requested to specify the predominant site as well as other sites of itching experienced by them. They were also asked to state whether the discomfort of pruritus was more during dialysis or they felt better after dialysis. All information thus obtained along with the age and sex of the patients was recorded and subjected to simple descriptive statistics including mean, mode and chi-square test. ,
The major limitation of the study is that any assessment based on subjective description will always have limitations of reproducibility. In pruritus, the severity may vary or may be fluctuating.  Also, the patients have to recall the symptoms and site, particularly if the pruritis is not distressing to them. This leads to recall bias. To overcome this, patients were interviewed repeatedly by the authors.
| Results|| |
The overall prevalence of pruritus in the present study was 67% and it was independent of sex of the patient. Thus, pruritus was observed in 27 of 40 males (67.5%) and 40 of 60 females (66.7%). The age of the patients ranged from 13 to 80 years. The distribution of cases in relation to age, sex and pruritus is shown in [Table - 1].
When pruritus was assessed for severity, it was found to be mild in 34 (50.8%), moderate in 22 (32.8%) and severe in 11 (16.4%). The severity of pruritus in relation to sex of the patient is provided in [Table - 2].
The prevalence of pruritus among those below the age of 45 years was independent of age-group or sex, whereas it was more (p < 0.05) in women aged 45 years and above when compared with men of similar agegroup as well as women below 45 years of age (p < 0.02).
The site of pruritus varied considerably. Most of the patients experienced pruritus in more than one site or throughout the body. The predominant sites of pruritus included: eyes and ears in six each, face in seven, nose in nine, scalp in 10, axillae and genitalia in 14 each, upper limbs in 21, lower limbs in 25, chest and abdomen in 30, and back in 36 cases.
Discomfort of pruritus was more during HD in three patients (two males and one female), but it was reduced remarkably in 10 others (4 males and 6 females) after a dialysis session.
| Discussion|| |
Pruritus has been estimated to occur in 10 to 30% of uremic patients.  The toxins of uremia have been implicated in the causation of pruritus. This notion has certain pitfalls e.g., pruritus has not been noticed in acute renal failure nor is it seen in every patient with chronic renal failure.  Even after institution of dialysis treatment of whatever kind, the frequency of pruritus was not reduced. , Also, pruritus has been shown to be independent of duration of uremia, adequacy of dialysis and underlying renal disease. ,,
The various factors that have been incriminated in the causation of pruritus include hyperparathyroidism, hypercalcemia, hyperphosphatemia, raised calcium-phosphorus product, deposition of calcium salts in dermal structures, hypomagnesemia, xerosis, abnormal sweat gland functions, mast cell proliferation with elevated levels of histamine, sensitization, iron deficiency anemia, middle molecules, bile acids, hypervitaminosis A, deposition of some substances in the skin, uremic neuropathy, microangiopathy and combinations thereof. ,,,, Currently, abnormal fatty acid metabolism has been suggested to cause uremic itch. 
The overall prevalence of pruritus among our study population was 67% and it is comparable with the published reports as shown in [Table - 3]. ,,,, In the present study, pruritus was noticed in all age-groups and in both sexes as has been reported elsewhere.  However, sub-group analysis revealed that pruritus was significantly more in women aged 45 years and above, when compared with women below 45 years (p < 0.02). The significant difference among women belonging to pre- and post-menopausal age-groups makes one consider the possible role of female sex hormones for this variation. However, further studies are required to confirm this observation.
Most frequent areas of itching in patients with chronic renal failure are axillae, scalp, nose and ears, although the location changes frequently. , In the present study, pruritus was observed in various parts of the body with a tendency to conform more to spinal dermatomes which is similar to the observations of Schultz and Roenigk. 
We noticed that the discomfort of pruritus was more during HD in three patients, but dialysis gave relief for the day in 10 others. Aggravation of pruritus has been noticed during HD by other workers too.  Although Masi and Cohen showed an inverse correlation between severity of itching and the efficiency of dialysis, itch was unrelated to adequacy of HD in the series of Carmichael et al. , Moreover, itching has been shown to have distinct paroxysms during dialysis and at night. ,
The possible reasons for the variation in the prevalence, severity and site of itching are individual tolerance, threshold for itch, race and ethnic background. Moreover, the assessment of itch is also a subjective one as it is based on perception, which is influenced by socio-economic, cultural, educational, and living environment. In addition, different authors have used different study methods. ,,
A wide variety of treatment modalities have been tried for pruritus in patients on dialysis but without satisfactory relief. ,,, Nielson et al noticed disappearance of pruritus after transplantation.In two of their transplant patients, pruritus disappeared immediately after transplantation even before normalization of calcium/phosphorus metabolism could be expected. Gilchrest et al observed reversibility of cutaneous signs and symptoms following successful renal transplantation.  We also noted disappearance of pruritus following successful renal transplantation in three of our patients who had itching before transplantation. At the same time it was painful to see the recurrence of pruritus in two of the cases included in the present study following graft loss. These two individuals were free of uremic itch as long as their renal allograft was functioning. This suggests the possibility of a "pruritogenic factor" produced in the body, which is neither excreted nor metabolized or removed during dialysis, but gets accumulated and contributes to cutaneous symptoms and signs of uremia either alone or in combination of various other factors described earlier.
In all circumstances, before attributing pruritus of chronic renal failure to renal failure per se, one should exclude other potentially treatable causes. One should also remember that pruritus might be associated with medicines used such as anti-hypertensives (captopril, nifedipine and prazocin) as well as H 2 receptor blockers (ranitidine).  Whenever a patient has diurnal variation in the itch, one should exclude the relationship with pets or occupation. When a patient on dialysis develops pruritus for the first time, we should exclude reaction to dialyzer membranes, skin diseases including scabies, drug reaction, underlying malignancy, especially lymphoma, systemic disorders and pregnancy (in women of reproductive age).
Although enough is known to determine a reasonable series of steps in approaching a patient's uremic pruritus, more research is needed to understand the pathophysiology of this condition and to establish more reliable treatment. 
In conclusion, pruritus, in our study, was observed in all age-groups and both sexes of patients with ESRF. The intensity and site of itching and relationship to HD varied among different individuals. The importance of looking for secondary causes for pruritus has been stressed and the relief obtained with transplantation is being mentioned.
| Acknowledgements|| |
We thank Mr. Joseph D' Cunha for typing the manuscript.
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Department of Nephrology, Samtah General Hospital, Samtah, Gizan
[Table - 1], [Table - 2], [Table - 3]