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Dr. Liossatou:
Hello, this is CE with GLC, and I'm Dr. Anastasia Liossatou. And in this episode, I'm going to present a patient with CKD-associated pruritus, and we are going to discuss how the burden of CKD-associated pruritus can be assessed, as well as the need for treatment.

So let us consider a 67-year-old patient receiving maintenance hemodialysis who reports persistent itching for more than 6 months. The itching, let's say, is most severe during the evening and night, leading to sleep disruption, fatigue, irritability, and difficulty in his concentration during the day.

So when assessing a patient with suspected chronic kidney disease-associated pruritus, it is important not only to ask whether itching is present, but it is important also to quantify itch severity and understand its impact on quality of life.

A useful starting point is the Worst Itch Numeric Rating Scale, WI-NRS, which asks the patient to rate their worst itching during the previous 24 hours, and this is on a scale from 0 to 10. In our patient, the baseline WI-NRS score is 8, indicating severe pruritus as a substantial symptom burden.

While WI-NRS serves as a core metric for severity assessment and treatment monitoring, additional validated tools can provide important understanding of a patient's experience.

We have other tools, such as the 5-D Itch Scale that evaluates 5 dimensions of itching: duration, degree, direction, disability, and distribution; the SADS, Self-Assessment Disease Severity Scale, that allows patients to categorize the overall severity of the condition; and also Skindex-10 assesses the impact of itching on emotions, daily functioning, and overall quality of life.

Now, in our patient case, these assessments reveal that the itch is not simply a physical symptom. It is affecting sleep quality, mood, social interactions, and overall well-being. This highlights why CKD-associated pruritus should be recognized as a significant chronic condition requiring active management.

Dr. Alberici:
All the scales you mentioned are very useful, but in the end, we need to find something that work for us in the everyday clinical practice. And as you mentioned, the 2 scales that are more useful from that point of view are probably WI-NRS and the SADS. These scales allowed us to stratify the severity of the itch and allowed us to monitor the symptom throughout the time.

The WI-NRS is relatively easy, as already mentioned. Basically, we ask the patient to grade the worst itch during the previous 24 hours from 0 to 10. We consider it a mild itch if the score ranges from 1 to 3, moderate if the score ranges from 4 to 6, severe if the score is higher than 7.

The Self-Assessment Disease Severity Scale, SADS, assesses through key aspects in our patient: if the patient experiences scratches on the skin, if the patient experiences trouble in sleeping, if the patient experiences psychological consequences of the itch. And this allows us to stratify the patients in mild, moderate, or severe. According to the clinical practice of different centers, patients with moderate and severe CKD-aP require consideration for further treatment.

As already mentioned, it is very important to screen our patients for CKD-aP. This screening needs to be repeated throughout the time because we know that CKD-aP is a chronic condition, it fluctuates, and the patient may have a negative assessment that may become positive later on. And using these scales is very, very important to assess how the symptoms evolve longitudinally, especially after a treatment is started.

So our suggestion is basically to be able to screen our population with WI-NRS, with SADS to begin with, and to stratify the severity and to decide whether or not further treatment should be considered.

Dr. Liossatou:
Yes, it's very important that we utilize in clinical practice tools that are easy for our patients to use. And also, time is a component that we need to take into consideration. But in any case, successful management of CKD-aP is not only about reducing its intensity, but also about restoring quality of life, improving sleep, and enhancing overall patient well-being. And we can only do that by quantifying these data and from our patients in clinical practice.

So returning to our patient, after treatment initiation the WI-NRS decreases from 8 to 3. We observed sleep quality that is improved, and the patient reports being able to participate again in normal daily activities. And this demonstrates that successful management of CKD-aP is reducing itch intensity and it is restoring quality of life, improving sleep, and enhancing overall patient well-being.

So I hope you have enjoyed this brief overview. Thank you for listening.

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