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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 3  |  Issue : 4  |  Page : 114-117

Pruritus in Patients on Maintenance Hemodialysis in Benin City, Edo State, Nigeria


1 Department of Medicine, Renal Unit, Delta State University Teaching Hospital, Oghara, Delta State, Nigeria
2 Department of Medicine, Renal Unit, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
3 Department of Surgery, Delta State University Teaching Hospital, Oghara, Delta State, Nigeria

Date of Web Publication7-Nov-2016

Correspondence Address:
Bemigho Ayo Odonmeta
Department of Medicine, Renal Unit, Delta State University Teaching Hospital, Oghara, Delta State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2394-2916.193498

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  Abstract 

Background and Objectives: Pruritus is an unpleasant cutaneous sensation prompting a desire to scratch. It can be very disturbing and is common in patients on maintenance hemodialysis (HD). Its pathogenesis is not very clear but has been attributed to diverse factors including uremia and iron deficiency anemia. The aims and objectives of this study are to determine the frequency of pruritus in HD patients in Benin City, to evaluate the relationship of pruritus in these patients with age, sex, body mass index (BMI), skin changes, peripheral neuropathy, duration of dialysis, and laboratory findings including packed cell volume (PCV), creatinine, urea, calcium, and phosphate, and to get the percentage of patients with increasing pruritus during and after dialysis. Methods: Consenting patients on maintenance HD were consecutively recruited into the study. Some relevant clinical and laboratory parameters (age, sex, BMI, skin changes, neuropathy, presence of pruritus, severity and intensity of pruritus, serum urea, creatinine, calcium, and phosphate) were evaluated using the SPSS version 17 package. Results: A total of fifty patients participated in the study. Twenty-four (48%) of these patients had pruritus. Of the 24 patients with pruritus, 14 (58.3%) were males while 10 (41.7%) were females. The mean age, BMI, and duration of HD of the patients with pruritus were 51.0 ± 13.61 years, 23.3 ± 1.77 kg/m 2 , and 7.4 ± 9.31 months, respectively. In addition, the mean serum urea, calcium, and PCV of the patients were 252.1 ± 65.10 mg/dL, 7.0 ± 1.04 mg/dL, and 25.5% ±4.38%, respectively. Eight (33.3%) had an increasing intensity of pruritus during and after HD. Twelve (50%) of the patients had mild pruritus while another 12 (50%) had moderate pruritus. There was no case of severe pruritus. Anemia, serum urea, duration of HD and increasing the age of patients were found to be significantly related to pruritus. Conclusion: Pruritus is relatively prevalent among our patients on maintenance HD and factors significantly associated with this condition include anemia, serum urea, and increasing the age of the patient as well as duration on HD.

Keywords: Chronic kidney disease, hemodialysis, pruritus


How to cite this article:
Odonmeta BA, Unuigbe E, Otene CI. Pruritus in Patients on Maintenance Hemodialysis in Benin City, Edo State, Nigeria. J Integr Nephrol Androl 2016;3:114-7

How to cite this URL:
Odonmeta BA, Unuigbe E, Otene CI. Pruritus in Patients on Maintenance Hemodialysis in Benin City, Edo State, Nigeria. J Integr Nephrol Androl [serial online] 2016 [cited 2019 Jun 26];3:114-7. Available from: http://www.journal-ina.com/text.asp?2016/3/4/114/193498


  Introduction Top


Pruritus is an unpleasant cutaneous sensation prompting a desire to scratch. It is common among patients receiving hemodialysis (HD). The percentage of HD patients suffering from pruritus varies reportedly from 10% to 90%. [1],[2],[3],[4],[5],[6],[7] Pruritus was found in 41.9% of HD patients in Iran, 48% in Tel Aviv and 74.4% in Morocco. Interestingly, pruritus is typically not seen in acute renal failure. [8]

In clinical medicine, pruritus may be a symptom of skin disorders or may complicate a large number of different diseases. Among them, chronic renal failure is probably the most common cause of itching.

According to many sources, more than half of patients undergoing HD complain of varying degrees of pruritus. [ 7],[9],[10],[11] The mechanism underlying pruritus is poorly understood; current theories include secondary hyperparathyroidism, divalent-ion abnormalities, histamine, allergic sensitization, proliferation of skin mast cells, iron deficiency anaemia, hypervitaminosis A, xerosis, neuropathy and neurologic changes, opioid system involvement (under stimulation of k receptors or overexpression of μ receptors), cytokines, serum bile acids, nitric oxide, or some combination of these. [9],[12]

Pruritus usually begins about 6 months after the start of dialysis, [13] and some authors have shown a significant positive relationship with the duration of HD. [12]

Itch is transmitted by dedicated C neurons. Receptor activation will lead to a local release of substance P that activates dermal mast cells, resulting in an increased release of tumor necrosis factor-α which in turn sensitizes nociceptor nerve terminals and enhances their responsiveness. [14] Substance P, a neurotransmitter widely distributed in the afferent sensory neurons, can communicate pain and some itching sensations from the periphery to the central nervous system and is considered potentially responsible for itching. [15],[16]

In chronic kidney disease (CKD), some of the causes of pruritus include anemia, hyperparathyroidism, calcium phosphate product deposition in the skin, uremia, and the use of less biocompatible membranes in HD and a host of others. A relationship between dialysis adequacy and pruritus has been suggested in some studies [17] and rejected in others. [18]

Aims and objectives

The aims and objectives of this study are:

1. To determine the frequency of pruritus in HD patients in Benin City

2. To evaluate the relationship of pruritus in these patients with age, sex, body mass index ( BMI), skin changes, peripheral neuropathy, duration of dialysis, and laboratory findings including packed cell volume (PCV), creatinine, urea, calcium, and phosphate

3. To get the percentage of patients with increasing pruritus during and after dialysis.


  Methods Top


Fifty patients on maintenance HD were enrolled for this descriptive study after obtaining consent from them. The patients all had CKD of varying etiology and had been on HD for a minimum of 3 months. The age range of patients selected was 18-65 years and study was carried out at the University of Benin Teaching Hospital, Edo State, Nigeria a questionnaire [Appendix 1] was designed for this purpose. Pruritus was graded into mild (episodic and localized pruritus without disturbance in usual work and sleep), moderate (generalized and continuous pruritus without sleep disturbance), and severe (generalized and continuous pruritus with sleep disturbance).



Some relevant clinical and laboratory parameters (age, sex, BMI, skin changes, neuropathy, presence of pruritus, severity and intensity of pruritus, serum urea, creatinine, calcium, and phosphate) were evaluated using the Statistical analysis software package (SPSS) version 17 (SPSS Inc., Chicago). A Pearson's correlation was also done to show the association of pruritus with the various parameters.


  Results Top


A total of fifty patients participated in the study. Twenty-four (48%) of these patients had pruritus on HD.

PCV, serum urea, duration of HD, and increasing the age of patients were found to be significantly related to pruritus. (Using Pearson's correlation as shown above).


  Discussion Top


Pruritus is common in CKD patients undergoing hemodialysis. It may be a symptom of skin disorder but can be found in many chronic medical illnesses. It can be quite disturbing to the patient. The association between uremia and pruritus has already been reported more than a century ago. [19] From this study, the frequency of pruritus in hemodialysis patients in Benin City, Nigeria was found to be 48% [Figure 1]. This is similar to what was obtained in Iran and Tel Aviv. The frequency in Morocco was however significantly higher. The mean age, BMI, and duration of hemodialysis of the patients with pruritus were 51.0 ± 13.61 years, 23.3 ± 1.77 kg/m 2 , and 7.4 ± 9.31 months, respectively. Furthermore, the mean serum urea, calcium, and PCV of the patients were 252.1 ± 65.10 mg/dL, 7.0 ± 1.04 mg/dL, and 25.5% ± 4.38%, respectively [Table 1].
Figure 1: Pie chart of hemodialysis patients with and without pruritus

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Table 1: Mean and standard deviation of variables


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The serum urea levels in this study were elevated, and this is suggested to be a factor for the increased frequency of pruritus because the patients do not get adequate dialysis since they will need to pay from their pockets for the procedure.

Pathogenesis of pruritus is still unknown. The problem is worsened by the emotional conflicts usually present in dialysis patients. The mechanism underlying uremic pruritus is poorly understood, a combination of these have been hypothesized.

This study revealed that increasing age, anemia, increased serum urea, and longer duration on hemodialysis are associated with increasing frequency of pruritus in maintenance hemodialysis patients [Table 2]. With increasing duration of HD in our environment, the patient could get too dry, and since the use of high flux dialyzers is not so common, there could be deposition of middle molecular weight molecules and such increased tendency to itch.
Table 2: Correlation of pruritus with other variables


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With increasing age xerosis and ichthyosis is more and this can explain the increasing tendency to itch in HD patients. In most centers in Nigeria, there is no high flux HD, and hence the only small toxins are cleared. The middle and large molecules usually can remain accumulated in the skin and other organs of the patient following long duration on HD and thus increases the tendency to develop pruritus in HD.


  Conclusion Top


Pruritus is relatively prevalent amongst our patients on maintenance HD and factors significantly associated with this condition include anemia, serum urea, and age of the patient as well as duration on HD. About one-third of HD patients have an increasing intensity of pruritus during and after HD [Table 3].
Table 3: Increasing intensity


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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Young AW Jr., Sweeney EW, David DS, Cheigh J, Hochgelerenl EL, Sakai S, et al. Dermatologic evaluation of pruritus in patients on hemodialysis. N Y State J Med 1973;73:2670-4.  Back to cited text no. 1
    
2.
Matsumoto M, Ichimaru K, Horie A. Pruritus and mast cell proliferation of the skin in end stage renal failure. Clin Nephrol 1985;23:285-8.  Back to cited text no. 2
    
3.
Hiroshige K, Kabashima N, Takasugi M, Kuroiwa A. Optimal dialysis improves uremic pruritus. Am J Kidney Dis 1995;25:413-9.  Back to cited text no. 3
    
4.
Virga G, Mastrosimone S, Amici G, Munaretto G, Gastaldon F, Bonadonna A. Symptoms in hemodialysis patients and their relationship with biochemical and demographic parameters. Int J Artif Organs 1998;21:788-93.  Back to cited text no. 4
    
5.
Goicoechea M, de Sequera P, Ochando A, Andrea C, Caramelo C. Uremic pruritus: An unresolved problem in hemodialysis patients. Nephron 1999;82:73-4.  Back to cited text no. 5
    
6.
Merkus MP, Jager KJ, Dekker FW, de Haan RJ, Boeschoten EW, Krediet RT. Physical symptoms and quality of life in patients on chronic dialysis: Results of the Netherlands Cooperative Study on Adequacy of Dialysis (NECOSAD). Nephrol Dial Transplant 1999;14:1163-70.  Back to cited text no. 6
    
7.
Virga G, Visentin I, La Milia V, Bonadonna A. Inflammation and pruritus in haemodialysis patients. Nephrol Dial Transplant 2002;17:2164-9.  Back to cited text no. 7
    
8.
Mistik S, Utas S, Ferahbas A, Tokgoz B, Unsal G, Sahan H, et al. An epidemiology study of patients with uremic pruritus. J Eur Acad Dermatol Venereol 2006;20:672-8.  Back to cited text no. 8
    
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Urbonas A, Schwartz RA, Szepietowski JC. Uremic pruritus - An update. Am J Nephrol 2001;21:343-50.  Back to cited text no. 9
    
10.
Ståhle-Bäckdahl M. Uremic pruritus. Clinical and experimental studies. Acta Derm Venereol (Stockh) 1989;145:1-38.  Back to cited text no. 10
    
11.
Greaves MW. Pruritus. In: Champion RH, Burton JL, Burns DA, Breathnach SM, editors. Textbook of Dermatology. 6 th ed. London: Blackwell Science Ltd.; 1998. p. 623.  Back to cited text no. 11
    
12.
Szepietowski JC, Sikora M, Kusztal M, Salomon J, Magott M, Szepietowski T. Uremic pruritus: A clinical study of maintenance hemodialysis patients. J Dermatol 2002;29:621-7.  Back to cited text no. 12
    
13.
Robertson KE, Mueller BA. Uremic pruritus. Am J Health Syst Pharm 1996;53:2159-70.  Back to cited text no. 13
    
14.
Yosipovitch G, Greaves MW, Schmelz M. Itch. Lancet 2003;361:690-4.  Back to cited text no. 14
    
15.
Ko MJ, Yang JY, Wu HY, Hu FC, Chen SI, Tsai PJ, et al. Narrowband ultraviolet B phototherapy for patients with refractory uraemic pruritus: A randomized controlled trial. Br J Dermatol 2011;165:633-9.  Back to cited text no. 15
    
16.
Tarng DC, Cho YL, Liu HN, Huang TP. Hemodialysis-related pruritus: A double-blind, placebo-controlled, crossover study of capsaicin 0.025% cream. Nephron 1996;72:617-22.  Back to cited text no. 16
    
17.
Masi CM, Cohen EP. Dialysis efficacy and itching in renal failure. Nephron 1992;62:257-61.  Back to cited text no. 17
    
18.
Ko MJ, Wu HY, Chen HY, Chiu YL, Hsu SP, Pai MF, et al. Uremic pruritus, dialysis adequacy, and metabolic profiles in hemodialysis patients: A prospective 5-year cohort study. PLoS One 2013;8:e71404.  Back to cited text no. 18
    
19.
Schwartz IF, Iaina A. Uraemic pruritus. Nephrol Dial Transplant 1999;14:834-9.  Back to cited text no. 19
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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