FACTORS ASSOCIATED WITH PRURITUS IN HEMODIALYSIS PATIENTS

THE AIM of the study was to investigate incidence of uremic pruritus and factors influencing the intensity of pruritus in hemodialysis patients. PATIENTS AND METHODS. 230 patients on chronic bicarbonate hemodialysis (Males/Females = 128/102) were investigated. Mean age of the patients was 50.8 ±11.9 (M±SD) (20-80 years), mean dialysis duration – 82 ± 66.8 months. The intensity of pruritus was assessed by a questionnaire scoring method (sum of scores of the pruritus intensity, distribution and frequency) and by a visual analog scale. Standard clinical and biochemical parameters were investigated in all patients. Echocardiography and bone densitometry (dual energy X-ray absorptiometry) were made in part of the patients. Medical and dialysis therapy were assessed. RESULTS. Uremic pruritus was frequently noted in hemodialysis patients: 63% of the patients complained of pruritus in the time of investigation and 13% - in the past. Pruritus was mild in the majority of the patients. The most frequent localization was the back. The factors negatively influencing the intensity of pruritus were revealed: older age (t=2.21; p= 0.028), higher serum calcium (t=2.08; p= 0.039) and creatinine before dialysis (t=2.38; p=0,018), low bone mineral density of forearm (t=2.91; p= 0.0058), X-ray changes of the thoracic aorta (sclerosis and calcification, t=3.04; p=0.03), in patients with stenocardia, especially in a severe form (t=2.72; p= 0.007), the presence of dyspnoe (t=2.68; p=0.008), use of the dialysers sterilized with ethylene oxide (t=2.62; p=0.001). CONCLUSION. Uremic pruritus frequently occurs in patients on hemodialysis. The factors responsible for severity of pruritus are older age, impaired calcium-phosphorus balance (higher serum calcium before diaslysis, low bone mineral density), higher azotemia, cardiovascular pathology (stenocardia, dyspnoe, X-ray changes of the aorta), use of dialysers sterilized chemically.

1. Robertson KE, Mueller BA. Uremic pruritus. Am J Health Syst Pharm 1996; 53: 2159-2170

2. Balaskas EV, Chu M, Uldall RP et al. Pruritus in continuous ambulatory peritoneal dialysis and hemodialysis patients. Perit Dial Int 1993; 13 [Suppl 2]: S527-532

3. Balaskas EV, Bamihas GI, Karamouzis M et al. Histamine and serotonin in uremic pruritus: effect of ondansetron in CAPD-pruritic patients. Nephron 1998; 78(4): 395-402

4. Zucker I, Yosipovitch G, David M et al. Prevalence and characterization of uremic pruritus in patients undergoing hemodialysis: uremic pruritus is still a major problem for patients with end-stage renal disease. J Am Acad Dermatol 2003; 49(5): 842-846

5. Szepietowski JC, Sikora M, Kusztal M et al. Uremic pruritus: a clinical study of maintenance hemodialysis patients. J Dermatol 2002; 29(10): 621-627

6. Adams J. Uremic pruritus related to duration, haemodialysis type in renal failure. J Dermatol 2002; 29(10): 621-627

7. Stahle-Backdahl M. Uremic pruritus. Clinical and experimental studies. Acta Derm Venereol Suppl(Stockh) 1989; 145: 1-38

8. Chou FF, H. J., Huang SC, Sheen-Chen SM. A study on pruritus after parathyroidectomy for secondary hyperparathyroidism. J Am Coll Surg 2000; 190(1): 65-70

9. Rashed A, Fahmi M, El Sayed M et al. Effectiveness of surgical parathyroidectomy for secondary hyperparathyroidism in renal dialysis patients in Qatar. Transplant Proc 2004; 36(6): 1815-1817

10. Cohen EP, Russell TJ, Garancis JC. Mast cells and calcium in severe uremic itching. Am J Med Sci 1992; 303(6): 360-365

11. Momose A, Kudo S, Sato M et al. Calcium ions are abnormally distributed in the skin of haemodialysis patients with uraemic pruritus. Nephrol Dial Transplant 2004; 19(8): 2061-2066

12. Blachley JD, Blankenship DM, Menter A et al. Uremic pruritus: skin divalent ion content and response to ultraviolet phototherapy. Am J Kidney Dis 1985; 5(5): 237-241

13. Friga V, Linos A, Linos DA. Is aluminum toxicity responsible for uremic pruritus in chronic hemodialysis patients? Nephron 1997; 75(1): 48-53

14. Hiroshige K, Kabashima N, Takasugi M et al. Optimal dialysis improves uremic pruritus. Am J Kidney Dis 1995; 25(3): 413-419

15. Subach RA, Marx MA. Evaluation of uremic pruritus at an outpatient hemodialysis unit. Ren Fail 2002; 24(5): 609-614

16. Masi CM, Cohen EP. Dialysis efficacy and itching in renal failure. Nephron 1992; 62:257-261

17. Mesic E, Tabakovic M, Habul V et al. Clinical characteristics of uremic pruritus in hemodialysis patients. Acta Med Croatica 2004; 58(5): 377-380

18. Jakic M. Does uremic pruritus in hemodialyzed patients disappear only with replacement therapy? Lijec Vjesn 1999; 121(4-5): 118-122

19. Dimkovic N, Djukanovic L, Radmilovic A et al. Uremic pruritus and skin mast cells. Nephron 1992; 61(1): 5-9

20. Rollino C, G. M., Piccoli G, Puiatti P et al. What is the role of sensitization in uremic pruritus? An allergologic study. Nephron 1991; 57(3): 319-322

21. Duo LJ. Electrical needle therapy of uremic pruritus. Nephron 1987; 47(3): 179-183

22. Mettang T, Fritz P, Weber J et al. Uremic pruritus in patients on hemodialysis or continuous ambulatory peritoneal dialysis (CAPD). The role of plasma histamine and skin mast cells. Clin Nephrol 1990; 34(3): 136-141

23. Hiroshige K, Kabashima N, Takasugi M et al. Optimal dialysis improves uremic pruritus. Am J Kidney Dis 1995; 25(3):413-419

24. Mettang T, Pauli-Magnus C, Alscher DM. Uraemic pruritus—new perspectives and insights from recent trials. Nephrol Dial Transplant 2002; 17: 1558-1563

25. Gilchrest BA, Stern RS, Steinman TI. Clinical features of pruritus among patients undergoing maintenance hemodialysis. Arch Dermatol 1982; 118(3): 154-156