Chronic Kidney Disease associated Pruritus (CKD-aP)

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Chronic Kidney Disease associated Pruritus (CKD-aP)

Itchy skin (also known as pruritus) is a common problem in people who have kidney disease. It affects nearly all patients with advanced kidney disease at some point in their kidney journey.

Itching can vary from being mild and only happening occasionally, to severe and constant in some patients. In fact, itching can disrupt your sleep and mood in severe cases, with a negative impact on your quality of life. This leaflet is designed to help you understand more about itching, how to manage it and the potential treatments available.

What causes itching in kidney disease?

Although the exact cause is not known, it is generally felt that the itching is caused by a combination of these factors:

Inflammation in the skin
Toxins building up that are usually cleared by the kidneys
An imbalance in the body’s nerve receptors
Some medications can cause itching too – for example: morphine-based painkillers. Talk to your doctor if you think this applies to you
Skin dryness is very common in people with kidney disease, and is associated with an increased risk of itching

How do we diagnose CKD-associated Pruritus?

Before diagnosing CKD-aP, it is important to rule out other causes of itching. This is because treatment of itching should be aimed at the cause. Sometimes patients have causes of itching that aren’t related to their kidney disease. Examples include eczema, psoriasis and some infections e.g. scabies. CKD-aP does not generally cause a rash, so please see your doctor if you notice visible changes in your skin.

In later stages, prolonged scratching does lead to changes in the skin, called excoriations and nodular prurigo in severe cases.

Scratching - However tempting, scratching will make the problem of itching worse. This is because scratching sets off more inflammation in the skin. It is really important not to scratch, if you can.

What can you do to manage skin itching?

We can break down the management of CKD-aP into things you can do yourself, and then look at treatments your doctor can prescribe.

Self-care
Topical therapy (skin creams)
Medical therapy
Other therapies
Keep your fingernails short to avoid scratching and traumatising the skin
Avoid wearing irritating fabrics e.g. wool. Stick to light, cotton clothing if you can
Keep the skin cool, use luke-warm water in the bath or shower
Try to avoid using soap or harsh skin cleansers as they strip the skin of its natural oils: use soap substitutes instead
Try to avoid using perfumed/fragranced skin products
Pat the skin dry gently – avoid rubbing the skin with a towel

Topical therapy

It’s very important to keep the skin hydrated as best you can.

Use an emollient (moisturiser) at least twice a day. Various types are available, try different ones to find the one that’s most useful to you.
Apply the emollient after your bath/shower – this will help trap moisture into the skin
Keep your emollients in the fridge – the extra cooling effect is helpful for itching

BE AWARE: all emollients contain paraffin or similar compounds – so they are FLAMMABLE. You must avoid smoking and other naked flames when using emollients. Take extra care with clothing/bedding/bandages that may become impregnated with emollients.

Medical therapies

If moisturising the skin isn’t enough to control your itching, please ask your doctor for advice. They may consider:

Medicated emollients – that may contain menthol or local anaesthetics e.g. lauromacrogol.
Tablets to suppress the nerve fibres that lead to the itching sensation e.g. gabapentin and pregabalin. Whilst effective, these medications need to be used with caution in kidney patients, and may cause side effects like feeling sleepy or dizzy
Antihistamines are often tried in patients with CKD-aP. Unfortunately, there is no good evidence that they help, but are certainly worth trying in difficult cases. They may help you sleep better if the itching affects you at night
If you are on haemodialysis, a newer medication, Difelikefalin, can be given intravenously to help with itching. Ask you kidney doctor for more details.
Some anti-depressants are thought to help with itching, but as yet, there is no good evidence that they help.

Other therapies

Here are some other options that can be considered if itching is difficult to control

Fatty acids e.g. evening primrose oil – they are thought to help with inflammation in the skin
UV light therapy
Acupuncture
Cognitive behavioural therapy/stress reduction – this may help you cope with the itching
If you’re on dialysis, it is important that your treatment is optimised – talk to your kidney doctor

Summary

Itching is a common problem is kidney patients, and can lead to significant distress. The most important ways of managing this condition are to keep your skin moist, and to avoid scratching. Please seek help from your doctor if your symptoms continue as there are several treatment options for this condition.

Reviewed by Jacqueline Nevols : Consultant Nephrologist Wessex Kidney Centre
August 2024 - Next review August 2024

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The National Kidney Federation cannot accept responsibility for information provided. The above is for guidance only. Patients are advised to seek further information from their own doctor.