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Dr. Fishbane:
This is CE with GLC. I'm Dr. Steven Fishbane, and here with me today is Dr. Nancy Helou.

Nancy, we've heard about the significant burden, the high prevalence of CKD-associated pruritus in people who are on hemodialysis. How does CKD-associated pruritus affect your patient's quality of life?

Dr. Helou:
The quality of life impact is profound because CKD-aP rarely occurs in isolation.

Patients often experience a cluster of symptoms: itch, scratching, poor sleep, fatigue, irritability, anxiety, depression, and sometimes difficulty working or engaging socially. Some may even withdraw socially because they feel embarrassed about visible scratch marks. Sleep is often also a central problem. Some wake up at night. If a patient is scratching at night, they may come to dialysis already exhausted, and that fatigue can make dialysis feel longer, reduce concentration, and worsen the emotional burden of treatment.

Over time, it can become part of dialysis distress. They are not only coping with demanding treatment schedules, but also with symptoms that follow them home.

The Swiss hemodialysis and hemodiafiltration study is useful here because it reminds us that even in settings with high dialysis standards, CKD-aP remain frequent, and in this study CKD-aP was associated with depression and with greater itch severity, while dialysis modality itself was not. So we should optimize dialysis, but we should not assume that optimization alone will resolve the condition.

The mechanisms are multifactorial and probably overlap. Skin barrier dysfunction can lower the threshold for itch. Retained uremic toxins, inflammation, neuropathic mechanisms, and imbalance in the opioid system may all contribute. And importantly, scratching can worsen the problem. It damages the skin barrier, increases local inflammation, and that inflammation can further intensify the itch. So patients can enter an itch-scratch-inflammation cycle that is very difficult to break.

So we should not only ask if dialysis is adequate, but also address it holistically, and ask: How is the patient sleeping? Are they depressed or anxious? Are they scratching frequently? Are they missing work or family activities? This reframes CKD-aP as a clinically meaningful condition that affects the whole person.

Dr. Fishbane:
Specifically interesting, I think, is the effect on sleep. Sleep quality, I believe to be so important in terms of people's quality of life and in terms of overall health. But if you're itching, there's very few things that can affect sleep as much, and this has been shown in studies. It's been shown in our studies in terms of improvement with therapy.

And the effect of loss of sleep on subsequent fatigue the next day and energy over time is so important.

It also—itching—contributes to depression, anxiety, and distress. Patients, like any of us, they don't want to have the feeling of scratching in front of others, including the care team.

A compounding factor to dialysis distress, it also leads to problems with employment, with social isolation, which I didn't really come to understand until later in my career, as patients would explain to me that they didn't want to get together, even with family members, and not be seen scratching and dealing with some of the skin signs that there's been itching.

It is a whole-person issue. We should never think of it as itching is minor, but we must think of it in terms of the fact that itching affects quality of life, itching affects sleep, and our studies show this repeatedly and show the ability to improve quality of life, sleep quality, and the patient's overall experience and quality of experience in life.

That's all the time we have. Thank you so much for listening.

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