Self-reported Pruritus and Clinical, Dialysis-Related, and Patient-Reported Outcomes in Hemodialysis Patients

Abstract Rationale & Objective Chronic kidney disease (CKD)-associated pruritus – generalized itching related to CKD – affects many aspects of hemodialysis patients' lives. However, information regarding the relationship between pruritus and several key outcomes in hemodialysis patients remains limited. Study design Prospective cohort Setting & Participants 23,264 hemodialysis patients from 21 countries in the Dialysis Outcomes and Practice Patterns Study (DOPPS) phases 4-6 (2009-2018) Exposure Pruritus severity, based on self-reported degree to which patients were bothered by itchy skin (5-category ordinal scale from "Not at all" to "Extremely") Outcomes Clinical, dialysis-related, and patient-reported outcomes Analytical approach Cox regression for time-to-event outcomes and modified Poisson regression for binary outcomes, adjusted for potential confounders Results The proportion of patients at least moderately bothered by pruritus was 37%, and 7% were extremely bothered. Compared to the reference group ("Not at all"), the adjusted mortality hazard ratio (HR) (95% CI) for patients extremely bothered by pruritus was 1.24 (1.08, 1.41). The rates of cardiovascular and infection-related deaths and hospitalizations were also higher for patients extremely vs. not at all bothered by pruritus (HRs range from 1.17 to 1.44). Patients extremely bothered by pruritus were also more likely to withdraw from dialysis and miss hemodialysis sessions and were less likely to be employed. Strong monotonic associations were observed between pruritus severity and longer recovery time from a hemodialysis session, lower physical and mental quality of life, increased depressive symptoms, and poorer sleep quality. Limitations Residual confounding, recall bias, non-response bias Conclusion Our findings demonstrate how diverse and far-reaching poor outcomes are for patients who experience CKD-associated pruritus, specifically those with more severe pruritus. There is need for change of practice patterns internationally to effectively identify and treat patients with pruritus in order to reduce symptom burden, and improve quality of life and possibly even survival.