Pruritus nephrogenic L29.8

Authors: Prof. Dr. med. Peter Altmeyer, Prof. Dr. med. Martina Bacharach-Buhles

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Last updated on: 29.10.2020

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Synonym(s)

Itching in renal failure; Nephrogenic itching; Nephrogenic Pruritus; Pruritus in chronic renal insufficiency; Pruritus in kidney diseases; Pruritus uremic; renal itching; renal pruritus; Uremic itching; Uremic Pruritus; uremic pruritus (engl.)

Definition
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Severe, non-suppressible permanent itching in chronic renal failure (stages 3a-5 - CDK stages according to KDIGO) due to retention of urinary substances. This pruritus occurs in about 25% of chronic renal patients. It can be localized or generalized. Dialysis patients also very often suffer from pronounced itching.

Itching in patients on dialysis is a permanent itch (probably as a sign of uremic neuropathy) or intermittent itching on dialysis (possibly hypersensitivity to substances of the extracorporeal circulation: plasticizers, latex, formaldehyde). A connection withi secondary hyperparathyroidism in uremia is discussed (e.g. renal insufficiency, skin changes). Remarkably, pruritus is a rare problem in dialysed children.

Etiopathogenesis
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Currently, the pathogenesis is still largely unexplained. Besides neuropathic disorders with possible receptor proliferation of the fibers, central nervous disorders are of interest. It is assumed that secondary hyperparthyroidism plays an etiopathogenetic role.

General therapy
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The following practical procedure is recommended for patients with chronic kidney disease (according to the guidelines of the German Society of Nephrology):

  • exclusion of pronounced anemia, severe secondary hyperparathyroidism or
  • an aluminium intoxication after many years of taking aluminium-containing phosphate binders.
  • If no cause for the itching can be identified, a topical treatment should be started first (see below)
  • If a topical therapy is not sufficient, in patients who are already on dialysis, an occasional relief of itching can be achieved by increasing the dialysis duration and frequency.
  • If these therapeutic approaches have not led to an alleviation of the symptoms, a systemic therapy should be applied.
  • A definitive elimination of the uremic pruritus is only possible through a kidney transplantation

External therapy
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The first choice therapy is UV radiation (UVB or high-dose UVA1).

Alternatively, capsaicin (0.01-0.5% in a cream base or as a shaking mixture, see below. Capsaicin as a formulation) is in some cases at least temporarily helpful. Cave! therapy costs! S.a. renal insufficiency, skin changes.

Intensified skin care: The integument of the patient with renal insufficiency is dry and scaly. Consistent external care measures such as fatty lotions twice a day (e.g. Excipial Lipolotio, Lipoderm Lotion) are indicated. External lotions with urea additives are generally well tolerated (e.g. 2-5% urea cream, nubral cream or excipial hydro- or lipolotio, R102, R104 ). Extremely sparing use of cleaning agents such as syndets or soaps. Instead, use hydrophilic body oils as washing substitutes (e.g. hydrophilic body oil or ready-to-use preparations that are generally used as oil baths, such as oil bath Cordes, Linola Fett N oil bath, Balneum Hermal oil bath).

Internal therapy
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The evidence for the efficacy of various drugs (such as gabapentin, gamma-linolenic acid) for the treatment of uremic pruritus is limited. For this reason, no general recommendations can be made.

Notice! Oral antihistamines are ineffective.

Alternative options that have been shown to be successful in studies: activated carbon 6 g/day, gabapentin 3 times/week 300 mg after dialysis.

Alternative: Recently, success has been described with ondansetron (e.g. Zofran 4-8 mg/day). Successes with low-dose erythropoietin have been described (18 U/kg bw/day, 3 times/week i.v.).

Alternative: Trial with non-steroidal anti-inflammatory drugs such as Metamizol 1000-2000 mg/day (e.g. Novalgin 2-4 tbl.)

Alternative: Opioid antagonists such as naltrexone (50 mg/day). The study results for naltrexone are contradictory. Considerable side effects such as nausea, vomiting, sleep disorders, dizziness.

Experimental: Thalidomide 100 mg/day showed an alleviating effect in controlled studies ( off-label use).

Literature
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  1. Legroux-Crespel E et al (2004) A Comparative Study on the Effects of Naltrexone and Loratadine on Uremic Pruritus. Dermatology 208: 326-330

  2. Mettang T (2016) Uremic Itch Management. Curr Probl Dermatol 50:133-141.

  3. Scherer JS et al (2017) Sleep Disorders, Restless Legs Syndrome, and Uremic Pruritus: Diagnosis and Treatment of Common Symptoms in Dialysis Patients. On J Kidney Dis 69:117-128.

  4. Ständer S et al (2006) Diagnostic and therapeutic procedures in chronic pruritis. J Dtsch Dermatol Ges 4: 350-370

Incoming links (2)

Ondansetron; Renal pruritus;

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